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1173 OUTCOMES OF METALLIC RESONANCE® STENTS IN MALIGNANT URETERAL OBSTRUCTION
Vol. 187, No. 4S, Supplement, Monday, May 21, 2012
METHODS: Our database included 122 patients underwent DIUS following cystectomy. DIUS was done as previously described. Minimal follow up duration for these patients was six months after surgery. Frequency of evacuation, and continence during day and night times were recorded. Continence in this study means complete dryness without the use of any pads. The ability to discriminate between urine and stool were reported. Patients overall satisfaction was estimated according the following presumed score (score 1 to 5): score 1⫽ never or rarely satisfied, 2⫽ seldom satisfied, 3⫽ occasionally satisfied, 4⫽ often satisfied, and 5⫽ highly or always satisfied. RESULTS: Ninety five patients are available for the current evaluation. All patients were completely continent during day time and night. The average evacuation frequency was 3.9 times during day and 1.7 times during night. All patients were able to feel the desire to evacuate and to withhold evacuation after for an average time of 35 minutes. Fifty two patients (54.7%) could pass solid stools with minimal urine at the end once per day and the remaining evacuations consisting of clear urine only. The remaining 43 patients pass various degrees of urine and stools mixtures in most of their evacuants. Thirty two patients (33.7%) are able to differentiate between urine and stool sensation before going to evacuate.Satisfaction score revealed that 82 patients have score 5, none of the patients regretted the diversion or think of any form of undiversion. CONCLUSIONS: DIUS provides a high rate of continence both day and night, with satisfactory evacuation habits. Patients with DIUS can tolerate full bowel comfortably as long as they wish without any leakage Patients with DIUS experience good discrimination of urine and stool evacuants. Source of Funding: None
1172 PURE-LAPAROSCOPIC ORTHOTOPIC ILEAL NEOBLADDER AND ILEAL CONDUIT DURING RADICAL CYSTECTOMY Yin Changjun*, Nanjing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Most urinary diversion during laparoscopic radical cystectomy are performed extracorporeal. With development of laparoscopic techniques, intracorporeal urinary reconstruction may provide smaller incision and comparable surgical outcomes. The present study was to investigate the feasibility and efficiency of pure-laparoscopic orthotopic ileal neobladder and ileal conduit (Bricker operation) during radical cystectomy. METHODS: From March 2011 to August 2011, 21 patients(16 male and 5 female) with bladder cancer received laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder or ileal conduit. The pelvic lymphadectomy was firstly done followed by total cystectomy. In the orthotopic ileal neobladder group, a length of 40cm ileum was chosen for urinary reservoir. Anastomosis staplers was applied for harvesting ileal segment and recovery of ileal continuity. The lowest position of ileal segment was anastomosed with posterior urethra. Then antimesenteric ileal wall was incised with proximal 10cm ileum saved for anastomosis with bilateral ureter. Small bowel loops was rearranged in a U shape and ileal plate was sutured to formed reservoir. In the ileal conduit group, a length of 15cm ileum was chosen, anastomosis staplers was applied for harvesting ileal segment and recovery of ileal continuity. Then isolated ileal segment was anastomosed with bilateral ureters. The distal end was sutured to the abdominal stoma. RESULTS: All procedures were performed successfully without open conversion and major intra/post-operative complications. Mean total operative time was 310min. Mean intraoperative blood loss was 520ml and 6 case received blood transfusion. Mean bowl movement occurred on 3 day and all patients have fluid diet on 5 day. In orthotopic ileal neobladder group, ureteric stent was kept for 14 days and catheter was removed on the 21 day and all patients got continence on discharge.
THE JOURNAL OF UROLOGY姞
e475
CONCLUSIONS: Pure-laparoscopic orthotopic ileal neobladder and ileal conduit during radical cystectomy is safe and feasible with the premise of laparoscopic skills. Source of Funding: None
1173 OUTCOMES OF METALLIC RESONANCE® STENTS IN MALIGNANT URETERAL OBSTRUCTION Zachariah Goldsmith*, Agnes Wang, Michael Lipkin, Lionel Banez, Muhammad Iqbal, Gasto´n Astroza, Michael Ferrandino, Brant Inman, Glenn Preminger, Durham, NC INTRODUCTION AND OBJECTIVES: Malignant ureteral obstruction (MUO) often necessitates chronic indwelling ureteral stents. The indwell time of a metallic ureteral stent has been suggested for up to 12 months, yet its clinical outcomes in MUO have not been completely defined. We sought to evaluate the outcomes of metallic ureteral stents placed for MUO, and to identify clinical predictors of failure or success. METHODS: All patients undergoing placement of the metallic Resonance® stent (Cook Medical) for MUO at Duke University were identified retrospectively. Patient demographics, oncologic variables, and clinical outcomes were examined. Stent failure was defined as unplanned stent exchange or nephrostomy tube placement for signs or symptoms of recurrent ureteral obstruction (recurrent hydronephrosis or increasing creatinine) or stent migration. Predictors of time to stent failure were assessed using Cox regression. RESULTS: A total of 37 stents were placed in 25 patients with MUO beginning in September 2010. Mean age was 65 years. Mean follow-up was 13.1 weeks. Twelve stents (32%, 12/37) were identified to fail. Progressive hydronephrosis (58%, 7/12) and increasing creatinine (50%, 6/12) were the most common signs of stent failure (not mutually-exclusive), followed by flank pain (25%, 3/12). Three failed stents (25%, 3/12) had migrated distally. No stents required removal for recurrent infection. The majority of stent failures (83%, 10/12) were identified during routine oncologic surveillance. Stent failure was managed by replacement with a new metallic stent (50%, 6/12), placing an alternative ureteral stent (17%, 2/12), nephrostomy tube (17%, 2/12), or observation (17%, 2/12). Cystoscopic evidence of malignant bladder invasion at the time of stent placement was associated with a significantly increased risk of failure (HR: 6.50, 95% CI: 1.45 – 29.20, P⫽0.015). Notably, symptomatic subcapsular hematomas were observed in three patients following metallic stent placement. Each of these cases was managed conservatively, but required an average of 4 imaging tests per patient with an estimated cost of $21,688. CONCLUSIONS: This is the largest series of MUO patients managed with the metallic Resonance® stent. Patients with a bladder tumor at the time of stent placement are at significantly higher risk for stent failure. Patients should be counseled on the risk of hematoma formation with this stent. With a 32% failure rate in this short-term series, long term follow-up is needed to determine the utility of this device for MUO. Source of Funding: None
1174 LONG-TERM FOLLOW-UP OF RENAL FUNCTION AFTER CONTINENT CUTANEOUS DIVERSION A.M. LUNDIANA Wiking Mansson*, Thomas Davidsson, Malmö, Sweden; Abai Xu, Guangzhou, China, People’s Republic of; Sigurdur Gudjonsson, Fredrik Liedberg, Malmö, Sweden INTRODUCTION AND OBJECTIVES: The Lundiana Pouch for continent cutaneous diversion is a modification of the Indiana Pouch. In the former the ileocaecal valve is diminished in diameter and fixed against the caecal wall as a flap valve using stapling instruments. The ureters are implanted with antirefluxing technique due to risk of inter-
METHODS: Our database included 122 patients underwent DIUS following cystectomy. DIUS was done as previously described. Minimal follow up duration for these patients was six months after surgery. Frequency of evacuation, and continence during day and night times were recorded. Continence in this study means complete dryness without the use of any pads. The ability to discriminate between urine and stool were reported. Patients overall satisfaction was estimated according the following presumed score (score 1 to 5): score 1⫽ never or rarely satisfied, 2⫽ seldom satisfied, 3⫽ occasionally satisfied, 4⫽ often satisfied, and 5⫽ highly or always satisfied. RESULTS: Ninety five patients are available for the current evaluation. All patients were completely continent during day time and night. The average evacuation frequency was 3.9 times during day and 1.7 times during night. All patients were able to feel the desire to evacuate and to withhold evacuation after for an average time of 35 minutes. Fifty two patients (54.7%) could pass solid stools with minimal urine at the end once per day and the remaining evacuations consisting of clear urine only. The remaining 43 patients pass various degrees of urine and stools mixtures in most of their evacuants. Thirty two patients (33.7%) are able to differentiate between urine and stool sensation before going to evacuate.Satisfaction score revealed that 82 patients have score 5, none of the patients regretted the diversion or think of any form of undiversion. CONCLUSIONS: DIUS provides a high rate of continence both day and night, with satisfactory evacuation habits. Patients with DIUS can tolerate full bowel comfortably as long as they wish without any leakage Patients with DIUS experience good discrimination of urine and stool evacuants. Source of Funding: None
1172 PURE-LAPAROSCOPIC ORTHOTOPIC ILEAL NEOBLADDER AND ILEAL CONDUIT DURING RADICAL CYSTECTOMY Yin Changjun*, Nanjing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Most urinary diversion during laparoscopic radical cystectomy are performed extracorporeal. With development of laparoscopic techniques, intracorporeal urinary reconstruction may provide smaller incision and comparable surgical outcomes. The present study was to investigate the feasibility and efficiency of pure-laparoscopic orthotopic ileal neobladder and ileal conduit (Bricker operation) during radical cystectomy. METHODS: From March 2011 to August 2011, 21 patients(16 male and 5 female) with bladder cancer received laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder or ileal conduit. The pelvic lymphadectomy was firstly done followed by total cystectomy. In the orthotopic ileal neobladder group, a length of 40cm ileum was chosen for urinary reservoir. Anastomosis staplers was applied for harvesting ileal segment and recovery of ileal continuity. The lowest position of ileal segment was anastomosed with posterior urethra. Then antimesenteric ileal wall was incised with proximal 10cm ileum saved for anastomosis with bilateral ureter. Small bowel loops was rearranged in a U shape and ileal plate was sutured to formed reservoir. In the ileal conduit group, a length of 15cm ileum was chosen, anastomosis staplers was applied for harvesting ileal segment and recovery of ileal continuity. Then isolated ileal segment was anastomosed with bilateral ureters. The distal end was sutured to the abdominal stoma. RESULTS: All procedures were performed successfully without open conversion and major intra/post-operative complications. Mean total operative time was 310min. Mean intraoperative blood loss was 520ml and 6 case received blood transfusion. Mean bowl movement occurred on 3 day and all patients have fluid diet on 5 day. In orthotopic ileal neobladder group, ureteric stent was kept for 14 days and catheter was removed on the 21 day and all patients got continence on discharge.
THE JOURNAL OF UROLOGY姞
e475
CONCLUSIONS: Pure-laparoscopic orthotopic ileal neobladder and ileal conduit during radical cystectomy is safe and feasible with the premise of laparoscopic skills. Source of Funding: None
1173 OUTCOMES OF METALLIC RESONANCE® STENTS IN MALIGNANT URETERAL OBSTRUCTION Zachariah Goldsmith*, Agnes Wang, Michael Lipkin, Lionel Banez, Muhammad Iqbal, Gasto´n Astroza, Michael Ferrandino, Brant Inman, Glenn Preminger, Durham, NC INTRODUCTION AND OBJECTIVES: Malignant ureteral obstruction (MUO) often necessitates chronic indwelling ureteral stents. The indwell time of a metallic ureteral stent has been suggested for up to 12 months, yet its clinical outcomes in MUO have not been completely defined. We sought to evaluate the outcomes of metallic ureteral stents placed for MUO, and to identify clinical predictors of failure or success. METHODS: All patients undergoing placement of the metallic Resonance® stent (Cook Medical) for MUO at Duke University were identified retrospectively. Patient demographics, oncologic variables, and clinical outcomes were examined. Stent failure was defined as unplanned stent exchange or nephrostomy tube placement for signs or symptoms of recurrent ureteral obstruction (recurrent hydronephrosis or increasing creatinine) or stent migration. Predictors of time to stent failure were assessed using Cox regression. RESULTS: A total of 37 stents were placed in 25 patients with MUO beginning in September 2010. Mean age was 65 years. Mean follow-up was 13.1 weeks. Twelve stents (32%, 12/37) were identified to fail. Progressive hydronephrosis (58%, 7/12) and increasing creatinine (50%, 6/12) were the most common signs of stent failure (not mutually-exclusive), followed by flank pain (25%, 3/12). Three failed stents (25%, 3/12) had migrated distally. No stents required removal for recurrent infection. The majority of stent failures (83%, 10/12) were identified during routine oncologic surveillance. Stent failure was managed by replacement with a new metallic stent (50%, 6/12), placing an alternative ureteral stent (17%, 2/12), nephrostomy tube (17%, 2/12), or observation (17%, 2/12). Cystoscopic evidence of malignant bladder invasion at the time of stent placement was associated with a significantly increased risk of failure (HR: 6.50, 95% CI: 1.45 – 29.20, P⫽0.015). Notably, symptomatic subcapsular hematomas were observed in three patients following metallic stent placement. Each of these cases was managed conservatively, but required an average of 4 imaging tests per patient with an estimated cost of $21,688. CONCLUSIONS: This is the largest series of MUO patients managed with the metallic Resonance® stent. Patients with a bladder tumor at the time of stent placement are at significantly higher risk for stent failure. Patients should be counseled on the risk of hematoma formation with this stent. With a 32% failure rate in this short-term series, long term follow-up is needed to determine the utility of this device for MUO. Source of Funding: None
1174 LONG-TERM FOLLOW-UP OF RENAL FUNCTION AFTER CONTINENT CUTANEOUS DIVERSION A.M. LUNDIANA Wiking Mansson*, Thomas Davidsson, Malmö, Sweden; Abai Xu, Guangzhou, China, People’s Republic of; Sigurdur Gudjonsson, Fredrik Liedberg, Malmö, Sweden INTRODUCTION AND OBJECTIVES: The Lundiana Pouch for continent cutaneous diversion is a modification of the Indiana Pouch. In the former the ileocaecal valve is diminished in diameter and fixed against the caecal wall as a flap valve using stapling instruments. The ureters are implanted with antirefluxing technique due to risk of inter-