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Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications, and Functional Results of Four Different Diversions
842
european urology 53 (2008) 834–844
[22] Elmajian DA, Stein JP, Esrig D, et al. The Kock ileal neobladder: updated experience in 295 male patients. J Urol 1996;156:920–5. [23] Shaaban AA, Mosbah A, El-Bahnasawy MS, Madbouly K, Ghoneim MA. The urethral Kock pouch: long-term functional and oncological results in men. BJU Int 2003;92: 429–35.
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications and Functional Results of Four Different Diversions Paolo Puppo Urology Department, National Institute for Cancer Research, Genoa, Italy [email protected] The choice of the urinary diversion after cystectomy depends on many factors ‘‘related to the patient’’ that are equally important: tumor stage, renal and hepatic function, and the ability of the patient to manage the diversion. The ability of the patient can only be judged by personal experience while talking to him, taking into account his social status and his capability to eventually perform a clean intermittent catheterization. The only oncologic contraindication to orthotopic diversion is the presence of tumor on the urethral margin, which can be safely checked intraoperatively. A stable severe renal or hepatic failure does not allow performance of a continent diversion because in some cases bowel disease (eg, chronic inflammatory disease) is also present. The report of Nieuwenhuijzen et al [1] shows that the incidence of complications does not differ significantly among ileal conduit according to
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications, and Functional Results of Four Different Diversions Ladislav Jarolı´m Department of Urology, Charles University 2nd Medical Faculty, Prague, Czech Republic [email protected] The current status of distribution of various urinary diversions after cystectomy for bladder cancer reflects a report of Hautman and coworkers evaluating > 7000 patients: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous
[24] Terrone C, Porpiglia F, Cracco C, et al. Supra-ampullar cystectomy and ileal neobladder. Eur Urol 2006;50: 1223–33. [25] Gerullis H, Kuemmel C, Popken G. Laparoscopic cystectomy with extracorporeal-assisted urinary diversion: experience with 34 patients. Eur Urol 2007;51:193–8.
Bricker, Indiana pouch, and orthotopic diversions [1]. This means that the choice of urinary diversion should not be influenced by the fear of complications, and consequently, the patient’s age, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, and performance status should not be taken into consideration when planning urinary diversion after cystectomy. However, operation time and blood loss may greatly influence the incidence of complications. Therefore, the volume of surgery per year (ie, the surgeon’s experience) is sometimes the factor ‘‘not related to the patient’’ that drives the decision-making process before any other type of consideration.
Reference [1] Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy: the association of clinical factors, complications, and functional results of four different diversions. Eur Urol 2008;53:834–44.
DOI: 10.1016/j.eururo.2007.09.009 DOI of original article: 10.1016/j.eururo.2007.09.008
diversion, 8%; and incontinent cutaneous diversion, 2% [1]. Nieuwenhuijzen et al in a series of 281 consecutive patients presented similar rates for neobladder (40%) and conduit (42%), whereas the rate was more than twice as high for continent cutaneous diversion at 18% [2]. Urinary diversion using more sophisticated methods with many particular tricky steps leads to higher risk of varied complications. If there are no early or late complications, an orthotopic bladder replacement is probably the best option of urinary diversion. Nevertheless, elderly patients tend to have worse continence due to muscular weakness. Long-term experience with follow-up
european urology 53 (2008) 834–844
periods > 10 yr demonstrates a sustained favorable voiding outcome with slightly increasing incontinence rates as patients age [3]. Risk of hypercontinence deserves consideration especially in female patients [4]. Results of continent cutaneous diversion in elderly patients may be influenced by the level of self-service. Thus, an appropriate type of diversion must be tailored for each patient. Complete daytime and nighttime continence for neobladder was achieved in Nieuwenhuijzen’s study in 90–96% and 67% of the patients, respectively [2]. These results were comparable with the large aforementioned review, 85–90% and 70–80% [1]. Continence rate [2] after continent cutaneous diversion (96%) was comparable with a recent report of Gallucci et al (91%) in a similar cohort [5]. Stricture of ureteroenteric anastomosis is a major complication treated with difficulty. Nieuwenhuijzen et al observed the stricture in 10.7%, less frequently in patients having a neobladder procedure, probably due to non-antireflux ureteral implantation. Prevalences of metabolic acidosis and vitamin B12 deficiency in the Nieuwenhuijzen et al study were common [2] but more easily treated.
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications, and Functional Results of Four Different Diversions Giovanni Muto S. Giovanni Bosco Hospital Turin, Piedmont, Italy [email protected] The article is a retrospective case series reporting on the diversion-related complication and functional outcomes of radical cystectomy with four different urinary diversions performed in patients affected by an established bladder cancer. The study is based on data from a single institution over a 15-yr span in a series of 281 patients. The authors comparatively analyzed the impact of the four urinary diversions for early and late complication rates, metabolic complications, and functional results. They concluded that orthotopic diversions, even providing good functional results, are burdened by a higher late complication rate [1]. From a general viewpoint it is still a much debated and not a proven evidence-based medicine topic as to what is the best urinary diversion after radical cystectomy and whether orthotopic ones
843
Functional results of any urinary diversion in appropriately selected patients are comparable and depend on careful cystectomy and subsequent meticulous reconstruction. References [1] Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. Urology 2007;69(Suppl 1):17–49. [2] Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy: the association of clinical factors, complications, and functional results of four different diversions. Eur Urol 2008;53:834–44. [3] Madersbacher S, Studer UE. Contemporary cystectomy and urinary diversion. World J Urol 2002;20:151–7. [4] Jarolı´m L, Babjuk M, Pecher SM, et al. Causes and treatment of residual urine volume after orthotopic bladder replacement in women. Eur Urol 2000;38:748–52. [5] Gallucci M, Leonardo G, Guaglianone S, et al. Simplified Indiana pouch with multiple teniamyotomies. Urology 2006;67:93–6.
DOI: 10.1016/j.eururo.2007.09.010 DOI of original article: 10.1016/j.eururo.2007.09.008
are superior to the conduits in terms of quality of life (QOL) as well [2]. This article reflects the current limitations and trends in this field. Most articles on urinary diversions are level of evidence 3 or 4. As a result, the higher grade of recommendation reached is C [3]. On the other hand, the attempt to make a comparison among the different types of urinary diversions clearly shows the changed paradigm. In fact, over the last decade we have witnessed a slow and progressive change in attitude from the initial priority for oncologic issues and upper urinary tract protection only to an increasing relevance of QOL issue and patient expectations as well. Nowadays, orthotopic bladder substitution, regardless of the patient’s gender and surgeon’s technique, accounts for around 50% of all urinary diversions [2]. This confirms the changed paradigm in our mind. All patients are potential candidates for orthotopic substitution; our task is to find out who is not. Unavoidably, the multiple variables involved in the decision-making process make it a difficult task from a clinical and scientific viewpoint as well.
european urology 53 (2008) 834–844
[22] Elmajian DA, Stein JP, Esrig D, et al. The Kock ileal neobladder: updated experience in 295 male patients. J Urol 1996;156:920–5. [23] Shaaban AA, Mosbah A, El-Bahnasawy MS, Madbouly K, Ghoneim MA. The urethral Kock pouch: long-term functional and oncological results in men. BJU Int 2003;92: 429–35.
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications and Functional Results of Four Different Diversions Paolo Puppo Urology Department, National Institute for Cancer Research, Genoa, Italy [email protected] The choice of the urinary diversion after cystectomy depends on many factors ‘‘related to the patient’’ that are equally important: tumor stage, renal and hepatic function, and the ability of the patient to manage the diversion. The ability of the patient can only be judged by personal experience while talking to him, taking into account his social status and his capability to eventually perform a clean intermittent catheterization. The only oncologic contraindication to orthotopic diversion is the presence of tumor on the urethral margin, which can be safely checked intraoperatively. A stable severe renal or hepatic failure does not allow performance of a continent diversion because in some cases bowel disease (eg, chronic inflammatory disease) is also present. The report of Nieuwenhuijzen et al [1] shows that the incidence of complications does not differ significantly among ileal conduit according to
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications, and Functional Results of Four Different Diversions Ladislav Jarolı´m Department of Urology, Charles University 2nd Medical Faculty, Prague, Czech Republic [email protected] The current status of distribution of various urinary diversions after cystectomy for bladder cancer reflects a report of Hautman and coworkers evaluating > 7000 patients: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous
[24] Terrone C, Porpiglia F, Cracco C, et al. Supra-ampullar cystectomy and ileal neobladder. Eur Urol 2006;50: 1223–33. [25] Gerullis H, Kuemmel C, Popken G. Laparoscopic cystectomy with extracorporeal-assisted urinary diversion: experience with 34 patients. Eur Urol 2007;51:193–8.
Bricker, Indiana pouch, and orthotopic diversions [1]. This means that the choice of urinary diversion should not be influenced by the fear of complications, and consequently, the patient’s age, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, and performance status should not be taken into consideration when planning urinary diversion after cystectomy. However, operation time and blood loss may greatly influence the incidence of complications. Therefore, the volume of surgery per year (ie, the surgeon’s experience) is sometimes the factor ‘‘not related to the patient’’ that drives the decision-making process before any other type of consideration.
Reference [1] Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy: the association of clinical factors, complications, and functional results of four different diversions. Eur Urol 2008;53:834–44.
DOI: 10.1016/j.eururo.2007.09.009 DOI of original article: 10.1016/j.eururo.2007.09.008
diversion, 8%; and incontinent cutaneous diversion, 2% [1]. Nieuwenhuijzen et al in a series of 281 consecutive patients presented similar rates for neobladder (40%) and conduit (42%), whereas the rate was more than twice as high for continent cutaneous diversion at 18% [2]. Urinary diversion using more sophisticated methods with many particular tricky steps leads to higher risk of varied complications. If there are no early or late complications, an orthotopic bladder replacement is probably the best option of urinary diversion. Nevertheless, elderly patients tend to have worse continence due to muscular weakness. Long-term experience with follow-up
european urology 53 (2008) 834–844
periods > 10 yr demonstrates a sustained favorable voiding outcome with slightly increasing incontinence rates as patients age [3]. Risk of hypercontinence deserves consideration especially in female patients [4]. Results of continent cutaneous diversion in elderly patients may be influenced by the level of self-service. Thus, an appropriate type of diversion must be tailored for each patient. Complete daytime and nighttime continence for neobladder was achieved in Nieuwenhuijzen’s study in 90–96% and 67% of the patients, respectively [2]. These results were comparable with the large aforementioned review, 85–90% and 70–80% [1]. Continence rate [2] after continent cutaneous diversion (96%) was comparable with a recent report of Gallucci et al (91%) in a similar cohort [5]. Stricture of ureteroenteric anastomosis is a major complication treated with difficulty. Nieuwenhuijzen et al observed the stricture in 10.7%, less frequently in patients having a neobladder procedure, probably due to non-antireflux ureteral implantation. Prevalences of metabolic acidosis and vitamin B12 deficiency in the Nieuwenhuijzen et al study were common [2] but more easily treated.
Editorial Comment on: Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications, and Functional Results of Four Different Diversions Giovanni Muto S. Giovanni Bosco Hospital Turin, Piedmont, Italy [email protected] The article is a retrospective case series reporting on the diversion-related complication and functional outcomes of radical cystectomy with four different urinary diversions performed in patients affected by an established bladder cancer. The study is based on data from a single institution over a 15-yr span in a series of 281 patients. The authors comparatively analyzed the impact of the four urinary diversions for early and late complication rates, metabolic complications, and functional results. They concluded that orthotopic diversions, even providing good functional results, are burdened by a higher late complication rate [1]. From a general viewpoint it is still a much debated and not a proven evidence-based medicine topic as to what is the best urinary diversion after radical cystectomy and whether orthotopic ones
843
Functional results of any urinary diversion in appropriately selected patients are comparable and depend on careful cystectomy and subsequent meticulous reconstruction. References [1] Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. Urology 2007;69(Suppl 1):17–49. [2] Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions after cystectomy: the association of clinical factors, complications, and functional results of four different diversions. Eur Urol 2008;53:834–44. [3] Madersbacher S, Studer UE. Contemporary cystectomy and urinary diversion. World J Urol 2002;20:151–7. [4] Jarolı´m L, Babjuk M, Pecher SM, et al. Causes and treatment of residual urine volume after orthotopic bladder replacement in women. Eur Urol 2000;38:748–52. [5] Gallucci M, Leonardo G, Guaglianone S, et al. Simplified Indiana pouch with multiple teniamyotomies. Urology 2006;67:93–6.
DOI: 10.1016/j.eururo.2007.09.010 DOI of original article: 10.1016/j.eururo.2007.09.008
are superior to the conduits in terms of quality of life (QOL) as well [2]. This article reflects the current limitations and trends in this field. Most articles on urinary diversions are level of evidence 3 or 4. As a result, the higher grade of recommendation reached is C [3]. On the other hand, the attempt to make a comparison among the different types of urinary diversions clearly shows the changed paradigm. In fact, over the last decade we have witnessed a slow and progressive change in attitude from the initial priority for oncologic issues and upper urinary tract protection only to an increasing relevance of QOL issue and patient expectations as well. Nowadays, orthotopic bladder substitution, regardless of the patient’s gender and surgeon’s technique, accounts for around 50% of all urinary diversions [2]. This confirms the changed paradigm in our mind. All patients are potential candidates for orthotopic substitution; our task is to find out who is not. Unavoidably, the multiple variables involved in the decision-making process make it a difficult task from a clinical and scientific viewpoint as well.