- Email: [email protected]
FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
0022-5347/00/1631-0056/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 163, 56 –59, January 2000 Printed in U.S.A.
FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER DIPEN J. PAREKH, W. BARRITT GILBERT
AND
JOSEPH A. SMITH, JR.
From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
ABSTRACT
Purpose: We reviewed our experience with orthotopic continent urinary reconstruction after radical cystectomy to determine the functional voiding patterns and compare different methods of reservoir construction. Materials and Methods: The study included 100 consecutive patients who underwent cystectomy and orthotopic neobladder. Reservoir construction consisted of a W-shaped ileal reservoir in 40 patients, ileal reservoir with afferent limb in 26, a Padua ileal reservoir in 18, right colon in 14 and sigmoid colon in 2. The functional voiding outcome was determined by a detailed patient interview and chart review. Results: There were no perioperative deaths. All patients regained good daytime urinary control and none required protective pads, although 18% used protective padding at night because of nocturnal leakage. Eight patients (8%) performed self-intermittent catheterization because of poor reservoir emptying. There were no substantial differences in outcomes among the various methods of reservoir construction. Conclusions: Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Comparable results can be achieved with use of either large bowel or ileum and with various methods of bowel folding as long as principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained. KEY WORDS: cystectomy; bladder; urinary reservoirs; continent
Continent urinary reconstruction with orthotopic placement of a neobladder avoids an abdominal stoma and may offer an improved quality of life for patients undergoing radical cystectomy for bladder cancer.1 Greater experience with the procedure and refinements in surgical techniques have decreased the morbidity of continent urinary reconstruction. Complication rates for this operation do not differ substantially from those that occur with ileal conduit diversion.2, 3 When measuring quality of life, however, an important outcome variable is the functional voiding pattern that occurs after orthotopic continent urinary reconstruction. Significant incontinence, stricture or failure to empty may detract substantially from any perceived quality of life advantages of reconstruction. A number of different methods of continent urinary reconstruction have been described with the procedure often assuming the name of the individual or institution responsible for some modification in technique.4 – 8 Use of various bowel segments and configurations is described in the literature along with reports from single institutions using 1 technique. However, there are few comparative studies of different methods of continent urinary reconstruction from within a single institution and performed by the same surgeons. We reviewed our recent experience with continent urinary reconstruction to determine functional voiding patterns and compare the different methods of reconstruction.
tient age was 59 years (range 26 to 80), and there were 84 men and 16 women. All patients had documented transitional cell carcinoma of the bladder (table 1). Preoperative platinum based chemotherapy was given to 4 patients, preoperative pelvic radiation to 3 and postoperative adjuvant chemotherapy to 8. Mean followup was 24 months (range 6 to 66). In general, the patients selected for orthotopic continent urinary reconstruction were those motivated toward avoidance of an abdominal stoma. All patients were informed preoperatively that there was the possibility of an alternate reconstruction being performed because of adverse intraoperative findings. In 1 patient a continent cutaneous reservoir was constructed because short bowel mesentery did not allow anastomosis to the urethra, and 5 patients underwent cutaneous diversion because of bulky nodal disease (3) or tumor at the prostatic apex (2). The type of neobladder was determined primarily by the surgeon preference and also by assessment of the anatomy. Reservoir construction consisted of a W-shaped ileal reservoir similar to that described by Hautmann et al6 in 40 patients (group 1), a W-shaped reservoir with a tubularized afferent limb in 26 (group 2), an ileal reservoir folded by the method described by Pagano et al9 in 18 (group 3), a detubularized right colon with an ileal patch in 14 (group 4) and a sigmoid neobladder in 2 (group 5).
MATERIALS AND METHODS
TABLE 1. Clinical and pathological stage of transitional cell carcinoma of the bladder
The study included 100 consecutive patients undergoing orthotopic continent urinary reconstruction during a 5-year period. We excluded from this analysis patients undergoing cystectomy with either an ileal conduit (62) or a continent cutaneous diversion (23) during the same period. Mean pa-
No. Clinical T1s T1 T2 T3–4
Accepted for publication August 27, 1999. 56
8 14 32 46
No. Pathological Po P1s P1 P2 P3–4
4 12 10 24 50
57
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
Ureteral stents were kept indwelling postoperatively for 1 week and catheter drainage of the pouch was maintained for 3 weeks. After catheter removal patients initiated spontaneous voiding via the Valsalva maneuver. Routine selfcatheterization was not used by any patient. The functional voiding patterns were obtained from detailed patient interviews and chart review. Lower urinary tract symptoms were classified as obstructive— hesitancy, straining, poor stream or intermittency and irritative—frequency, urgency and nocturia. Continence was strictly defined as excellent if the patient was completely dry at all times, good if there were occasional or sporadic episodes of leakage but no need for protection, fair if no more than a single pad was required for 24 hours and unsatisfactory if more than 1 pad was required within 24 hours. Incontinence was further divided into nocturnal or daytime. Postoperative followup included a post-void ultrasound of the pouch every 6 months to assess bladder emptying. Intermittent selfcatheterization was recommended if the post-void volumes routinely exceeded 150 cc. Self-catheterization for irrigation was used only if the patient experienced difficulty with spontaneous evacuation of mucous. To compare the functional results and rates of incontinence among the various groups statistically, the 1-way analysis of variance method using the Kruskal-Wallis test was applied, with p #0.05 considered significant. RESULTS
There were no postoperative deaths in this series. A single urethral dilation was required in 4 patients for a stricture at the anastomosis between the urethra and neobladder but none has had a recurrence of the stricture. Intermittent self-catheterization was necessary in 8 cases (8%) to obtain adequate emptying of the neobladder. These cases are distributed proportionately among the various methods of reservoir construction (table 2). No patient complained of obstructive symptoms other than occasional episodes of difficulty passing mucous, nor has persistent dysuria been reported by any patient. No metabolic problems requiring treatment have occurred and there have been no observed cases of secondary pouch infection. Daytime voiding frequency was 3.5 hours (range 1 to 5) and median number of nocturia episodes was 2 (range 0 to 7). All patients regained good daytime urinary control and
TABLE 2. Functional voiding outcome after orthotopic urinary reconstruction No. Pts. All pts. (group No.): 1 40 2 26 3 18 4 14 5 2 Totals Men (group No.): 1 2 3 4 5
100
No. Intermittent Self-Catheterization Required
No. Incontinence Requiring Pads at Night
3 3 1 1 –
7 5 3 3 0
8
18 p 5 0.985
33 22 15 12 2
3 2 0 1 0
6 5 2 3 0
Totals 84 Women (group No.): 1 7 2 4 3 3 4 2
6
16
1 0 1 0
1 0 1 0
2
2
Totals
16
none requires use of protective pads during the day. Of the patients 71 (71%) were completely dry at night while 11 (11%) have good control with sporadic episodes of minor nocturnal leakage managed with timed voiding or fluid restriction. Nocturnal continence was fair in 15 patients (15%) who require only a single pad, 2 perform intermittent selfcatheterization before bedtime to achieve complete emptying and avoid nocturnal incontinence, and 1 had significant nocturnal leakage which responded to 2 separate collagen injections (table 3). No differences were seen in the functional outcome among the different methods of continent urinary reconstruction. There was no statistically significant difference in achieving complete urinary control day and night among the different methods of reconstruction (table 2). DISCUSSION
The goal of orthotopic continent urinary reconstruction after cystectomy is improved quality of life.1, 10 Avoidance of an abdominal stoma alone may not accomplish this objective. Some patients would consider a stomal appliance less objectionable than a need for incontinence pads or, perhaps, selfcatheterization through the urethra. The functional voiding pattern is often the quality of life outcome of most consequence to patients choosing a neobladder and was the focus of our review. Our patients achieved excellent daytime urinary control and none required protective pads, although 18% used pads at night. Daytime frequency was every few hours and frequent episodes of nocturia were not a problem. Thus, the patients expressed a high degree of satisfaction with the voiding outcome. Presumably, the mechanism for urinary control after cystoprostatectomy with orthotopic reconstruction is the same as that after radical prostatectomy, that is preservation of the periurethral sphincter mechanism and the muscles of the pelvic floor.11 However, patients with orthotopic bladder reconstruction achieve daytime control more rapidly than those undergoing radical prostatectomy, and stress urinary incontinence is rarely an issue. This finding is likely a consequence of the lower voiding and resting pressures within a reservoir constructed of detubularized bowel compared to an intact bladder.3, 12 On the other hand, nocturnal enuresis is an unusual phenomenon after radical prostatectomy but it occurred at least to some extent in 29% of our patients, although only 16% wore a pad. The putative explanation is that the loss of normal neural feedback from an intact bladder does not permit reflexive tightening of the sphincter when bladder filling occurs during sleep.13 At any rate 71% of our patients were completely dry day and night, and only one sought additional treatment (collagen injection) because of problematic leakage. The rates of daytime incontinence in our series are lower than in comparable reports.7, 14 We used the same technique for dissection of the prostatic apex during cystoprostatectomy
TABLE 3. Orthotopic urinary reconstruction continence All pts. (100): Excellent Good Fair Poor Men (84): Excellent Good Fair Poor Women (16): Excellent Good Fair Poor
No. Daytime (%)
No. Nighttime (%)
93 (93) 7 (7) — —
71 (71) 11 (11) 15 (15) 3 (3)
79 (94) 5 (6) — —
58 (69) 10 (12) 14 (17) 2 (2)
14 (87) 2 (13) — —
13 (81) 1 (6) 1 (6) 1 (6)
58
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
as for radical prostatectomy. In women care was taken to avoid excessive periurethral dissection but no suspension of the vaginal vault or anterior urethropexy was performed. A nerve sparing procedure was not attempted in women. In addition, it has been our policy to create a reservoir with a capacity of at least 200 cc on the operating room table, which is somewhat larger than many other reported techniques and may account partially for our results.7 A possible consequence of excessive capacity is inadequate emptying. However, self-catheterization was required by only 8% of our patients. All others are able to empty adequately with the Valsalva maneuver or by the Crede´ method in a few cases. It is important for patients to avoid chronic over distention of the reservoir, and most void every few hours because of a sensation of fullness in the reservoir. However, we also instruct patients to void every 3 to 4 hours. The duration of followup in our series is relatively short, and it is possible that in time more patients will have problems with emptying. Numerous techniques for construction of orthotopic reservoirs have been described,4 –7 and virtually all involve folding of detubularized colon or ileum to create a spherically shaped reservoir. Each technique or bowel segment may have some particular advantages but it becomes difficult to compare results between different series. Our study is unique in that the same surgeons used different techniques within a similar time frame, eliminating many of the variables in comparing results. We observed no statistically significant differences in voiding patterns among the various methods used for reservoir construction. It appears that excellent results can be achieved with virtually any of the techniques as long as there is adherence to certain principles. First of all, as with radical prostatectomy, continence is highly dependent on an appropriate anatomical dissection of the prostatic apex with preservation of the periurethral sphincter mechanism. In women excessive dissection of the urethra or disruption of the integrity of the pelvic floor support must be avoided.15 In addition, construction of an adequate capacity reservoir is important.5, 12 Although some degree of stretching of the reservoir occurs with time, we observed a higher rate of incontinence, particularly at night, earlier in our experience when a smaller reservoir capacity was achieved. Delayed decompensation with poor emptying may be observed occasionally but the need for intermittent self-catheterization by our patients is no higher than that in most other reported series. Maintenance of low intrareservoir pressures without coordinated peristaltic contractions is important and accomplished with virtually all of the described techniques by using detubularized bowel. Moreover, construction of a reservoir with a spherical configuration gives the greatest capacity and lowest wall tension for a given length of bowel.5, 12 Our results are important in that they document an excellent functional voiding pattern after radical cystectomy with orthotopic bladder reconstruction. For appropriately selected patients continent urinary reconstruction can offer an improved quality of life compared to an abdominal stoma. Our experience with the various procedures within a single institution by the same surgeons allowed a valid comparison of techniques. The comparable results among various methods underscore the significance of maintaining certain principles common to all techniques in achieving the desired outcome. CONCLUSIONS
Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Daytime leakage is rare and minimal nocturnal incontinence occurs in a small percentage of patients. Comparable results can be achieved with use of either large bowel or ileum and with various described methods of bowel folding as long as
principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained. REFERENCES
1. Weijerman, P. C., Schurmans, J. R., Hop, W. C. et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology, 51: 51, 1998. 2. Benson, M. C., Slawin, K. M., Wechsler, M. H. et al: Analysis of continent versus standard urinary diversion. Br J Urol, 69: 156, 1992. 3. Gburek, B. M., Lieber, M. M. and Blute, M. L.: Comparison of studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. J Urol, 160: 721, 1998. 4. Reddy, P. K.: The colonic bladder. Urol Clin North Am, 18: 609, 1991. 5. Thu¨roff, J. W., Alken, P., Riedmiller, H. et al: 100 cases of Mainz pouch: continuing experience and evolution. J Urol, 140: 283, 1988. 6. Hautmann, R. E., Miller, K., Steiner, U. et al: The ileal neobladder: 6 years experience with more than 200 patients. J Urol, 150: 40, 1993. 7. Studer, U. E., Danuser, H., Merz, V. W. et al: Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol, 154: 49, 1995. 8. Elmajian, D. A., Stein, J. P., Esrig, D. et al: The Kock ileal neobladder: updated experience in 295 male patients. J Urol, 156: 920, 1996. 9. Pagano, F., Artibani, W., Aragona, F. et al: Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management. Arch Urol Esp, 50: 785, 1997. 10. Sullivan, L. D., Chow, V. D., Ko, D. S. et al: An evaluation of quality of life in patients with continent urinary diversions after cystectomy. Br J Urol, 81: 699, 1998. 11. Schlegel, P. N. and Walsh, P. C.: Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function. J Urol, 138: 1402, 1987. 12. Hinman, F., Jr.: Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol, 139: 519, 1988. 13. Jakobsen, H., Steven, K., Stigsby, B. et al: Pathogenesis of nocturnal urinary incontinence after ileocaecal bladder replacement. Continuous measurement of urethral closure pressure during sleep. Br J Urol, 59: 148, 1987. 14. Stein, J. P., Lieskovsky, G., Ginsberg, D. A. et al: The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique. J Urol, 159: 1836, 1998. 15. Hautmann, R. E., Paiss, T. and de Petriconi, R.: The ileal neobladder in women: 9 years of experience with 18 patients. J Urol, 155: 76, 1996. EDITORIAL COMMENT The authors report on the functional voiding outcome (patient interview and chart review) of 100 consecutive patients, including 16 women, undergoing cystectomy and orthotopic neobladder with 5 different techniques during a 5-year period with a mean followup of 2 years (range 6 to 66). Most reservoirs were made of ileum (84 of 100 cases). They explain their excellent results, that is all patients dry during the day, 71% dry at night and 8% dry on intermittent selfcatheterization, by the size of the reservoir initially created (greater than 200 ml.). This article comes from an excellent idea, namely assessing patient satisfaction with functional voiding outcome after different types of orthotopic neobladders. The main flaw of the study is its retrospective nature. Only patient interviews (obtained how long after the surgery and by whom?) and chart reviews were compiled to give a sense of overall “excellent” functional voiding outcome. Surprisingly, continence data are provided (table 3) but voiding parameters are not. The point made about all techniques faring equally well (only 2 cases of sigmoid colon) is arguable in the absence of objective outcomes, such as diaries indicating voided volumes, flow, residuals, and median and mean duration of followup for each group. For such an outcome study a validated questionnaire should be used, and a third party examiner or investigator should be charged with assessing the real degree of patient satisfaction. The aforementioned outcome variables should have been considered to avoid the subjectivity of the term “excellent”.
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER A minimum long-term followup of 2 years might have given more credibility to the data since initial results in general tend to appear more favorable than long-term data as acknowledged by the authors in their discussion. Some specific information should have been provided on the subgroup of 16 women. Table 2 indicates that at least 2 are on intermittent self-catheterization, implying either hypercontinence or secondary cystocele. This observation is consistent with other series in the literature. Although the authors state that no secondary pouch infection or metabolic changes were observed there is no information on how frequently and by what means these factors were evaluated. It is clear that in the mind of the authors urinary control equates with patient satisfaction. Other dimensions of quality of life should be considered, unless they were addressed in the “detailed patient interview”, which should have been provided as an Appendix. Despite these obvious shortcomings, this article provides new and favorable information for the motivated patient desiring orthotopic neobladder reconstruction after cystectomy. Philippe Zimmern Division of Urology University of Texas Southwestern Medical School Dallas, Texas
59
REPLY BY AUTHORS Cancer control is the most important outcome measure after radical cystectomy for bladder cancer but seemingly is unaffected by the method of urinary reconstruction. Radical cystectomy is a formidable procedure with the potential for significant morbidity or even mortality postoperatively. However, we have performed radical cystectomy in more than 260 consecutive patients with no perioperative mortality who were discharged home a median of 6 days postoperatively. Therefore, it is appropriate to focus on quality of life measures related to urinary reconstruction. Urinary control is only 1 measure which contributes to patient satisfaction with an orthotopic neobladder but it is important. Other aspects of the functional voiding pattern are also presented in our report, such as voiding frequency, failure to empty the reservoir adequately and metabolic or infectious complications. Our review is a focused analysis of the functional voiding pattern after orthotopic neobladder but this is only 1 aspect of the parameters which contribute to quality of life. We believe that several surgical principles contribute to our results, and reservoir size is only 1 of them. With adherence to principles and performance of surgical technique, comparable results can be achieved with a number of methods of reservoir construction.
Vol. 163, 56 –59, January 2000 Printed in U.S.A.
FUNCTIONAL LOWER URINARY TRACT VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER DIPEN J. PAREKH, W. BARRITT GILBERT
AND
JOSEPH A. SMITH, JR.
From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
ABSTRACT
Purpose: We reviewed our experience with orthotopic continent urinary reconstruction after radical cystectomy to determine the functional voiding patterns and compare different methods of reservoir construction. Materials and Methods: The study included 100 consecutive patients who underwent cystectomy and orthotopic neobladder. Reservoir construction consisted of a W-shaped ileal reservoir in 40 patients, ileal reservoir with afferent limb in 26, a Padua ileal reservoir in 18, right colon in 14 and sigmoid colon in 2. The functional voiding outcome was determined by a detailed patient interview and chart review. Results: There were no perioperative deaths. All patients regained good daytime urinary control and none required protective pads, although 18% used protective padding at night because of nocturnal leakage. Eight patients (8%) performed self-intermittent catheterization because of poor reservoir emptying. There were no substantial differences in outcomes among the various methods of reservoir construction. Conclusions: Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Comparable results can be achieved with use of either large bowel or ileum and with various methods of bowel folding as long as principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained. KEY WORDS: cystectomy; bladder; urinary reservoirs; continent
Continent urinary reconstruction with orthotopic placement of a neobladder avoids an abdominal stoma and may offer an improved quality of life for patients undergoing radical cystectomy for bladder cancer.1 Greater experience with the procedure and refinements in surgical techniques have decreased the morbidity of continent urinary reconstruction. Complication rates for this operation do not differ substantially from those that occur with ileal conduit diversion.2, 3 When measuring quality of life, however, an important outcome variable is the functional voiding pattern that occurs after orthotopic continent urinary reconstruction. Significant incontinence, stricture or failure to empty may detract substantially from any perceived quality of life advantages of reconstruction. A number of different methods of continent urinary reconstruction have been described with the procedure often assuming the name of the individual or institution responsible for some modification in technique.4 – 8 Use of various bowel segments and configurations is described in the literature along with reports from single institutions using 1 technique. However, there are few comparative studies of different methods of continent urinary reconstruction from within a single institution and performed by the same surgeons. We reviewed our recent experience with continent urinary reconstruction to determine functional voiding patterns and compare the different methods of reconstruction.
tient age was 59 years (range 26 to 80), and there were 84 men and 16 women. All patients had documented transitional cell carcinoma of the bladder (table 1). Preoperative platinum based chemotherapy was given to 4 patients, preoperative pelvic radiation to 3 and postoperative adjuvant chemotherapy to 8. Mean followup was 24 months (range 6 to 66). In general, the patients selected for orthotopic continent urinary reconstruction were those motivated toward avoidance of an abdominal stoma. All patients were informed preoperatively that there was the possibility of an alternate reconstruction being performed because of adverse intraoperative findings. In 1 patient a continent cutaneous reservoir was constructed because short bowel mesentery did not allow anastomosis to the urethra, and 5 patients underwent cutaneous diversion because of bulky nodal disease (3) or tumor at the prostatic apex (2). The type of neobladder was determined primarily by the surgeon preference and also by assessment of the anatomy. Reservoir construction consisted of a W-shaped ileal reservoir similar to that described by Hautmann et al6 in 40 patients (group 1), a W-shaped reservoir with a tubularized afferent limb in 26 (group 2), an ileal reservoir folded by the method described by Pagano et al9 in 18 (group 3), a detubularized right colon with an ileal patch in 14 (group 4) and a sigmoid neobladder in 2 (group 5).
MATERIALS AND METHODS
TABLE 1. Clinical and pathological stage of transitional cell carcinoma of the bladder
The study included 100 consecutive patients undergoing orthotopic continent urinary reconstruction during a 5-year period. We excluded from this analysis patients undergoing cystectomy with either an ileal conduit (62) or a continent cutaneous diversion (23) during the same period. Mean pa-
No. Clinical T1s T1 T2 T3–4
Accepted for publication August 27, 1999. 56
8 14 32 46
No. Pathological Po P1s P1 P2 P3–4
4 12 10 24 50
57
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
Ureteral stents were kept indwelling postoperatively for 1 week and catheter drainage of the pouch was maintained for 3 weeks. After catheter removal patients initiated spontaneous voiding via the Valsalva maneuver. Routine selfcatheterization was not used by any patient. The functional voiding patterns were obtained from detailed patient interviews and chart review. Lower urinary tract symptoms were classified as obstructive— hesitancy, straining, poor stream or intermittency and irritative—frequency, urgency and nocturia. Continence was strictly defined as excellent if the patient was completely dry at all times, good if there were occasional or sporadic episodes of leakage but no need for protection, fair if no more than a single pad was required for 24 hours and unsatisfactory if more than 1 pad was required within 24 hours. Incontinence was further divided into nocturnal or daytime. Postoperative followup included a post-void ultrasound of the pouch every 6 months to assess bladder emptying. Intermittent selfcatheterization was recommended if the post-void volumes routinely exceeded 150 cc. Self-catheterization for irrigation was used only if the patient experienced difficulty with spontaneous evacuation of mucous. To compare the functional results and rates of incontinence among the various groups statistically, the 1-way analysis of variance method using the Kruskal-Wallis test was applied, with p #0.05 considered significant. RESULTS
There were no postoperative deaths in this series. A single urethral dilation was required in 4 patients for a stricture at the anastomosis between the urethra and neobladder but none has had a recurrence of the stricture. Intermittent self-catheterization was necessary in 8 cases (8%) to obtain adequate emptying of the neobladder. These cases are distributed proportionately among the various methods of reservoir construction (table 2). No patient complained of obstructive symptoms other than occasional episodes of difficulty passing mucous, nor has persistent dysuria been reported by any patient. No metabolic problems requiring treatment have occurred and there have been no observed cases of secondary pouch infection. Daytime voiding frequency was 3.5 hours (range 1 to 5) and median number of nocturia episodes was 2 (range 0 to 7). All patients regained good daytime urinary control and
TABLE 2. Functional voiding outcome after orthotopic urinary reconstruction No. Pts. All pts. (group No.): 1 40 2 26 3 18 4 14 5 2 Totals Men (group No.): 1 2 3 4 5
100
No. Intermittent Self-Catheterization Required
No. Incontinence Requiring Pads at Night
3 3 1 1 –
7 5 3 3 0
8
18 p 5 0.985
33 22 15 12 2
3 2 0 1 0
6 5 2 3 0
Totals 84 Women (group No.): 1 7 2 4 3 3 4 2
6
16
1 0 1 0
1 0 1 0
2
2
Totals
16
none requires use of protective pads during the day. Of the patients 71 (71%) were completely dry at night while 11 (11%) have good control with sporadic episodes of minor nocturnal leakage managed with timed voiding or fluid restriction. Nocturnal continence was fair in 15 patients (15%) who require only a single pad, 2 perform intermittent selfcatheterization before bedtime to achieve complete emptying and avoid nocturnal incontinence, and 1 had significant nocturnal leakage which responded to 2 separate collagen injections (table 3). No differences were seen in the functional outcome among the different methods of continent urinary reconstruction. There was no statistically significant difference in achieving complete urinary control day and night among the different methods of reconstruction (table 2). DISCUSSION
The goal of orthotopic continent urinary reconstruction after cystectomy is improved quality of life.1, 10 Avoidance of an abdominal stoma alone may not accomplish this objective. Some patients would consider a stomal appliance less objectionable than a need for incontinence pads or, perhaps, selfcatheterization through the urethra. The functional voiding pattern is often the quality of life outcome of most consequence to patients choosing a neobladder and was the focus of our review. Our patients achieved excellent daytime urinary control and none required protective pads, although 18% used pads at night. Daytime frequency was every few hours and frequent episodes of nocturia were not a problem. Thus, the patients expressed a high degree of satisfaction with the voiding outcome. Presumably, the mechanism for urinary control after cystoprostatectomy with orthotopic reconstruction is the same as that after radical prostatectomy, that is preservation of the periurethral sphincter mechanism and the muscles of the pelvic floor.11 However, patients with orthotopic bladder reconstruction achieve daytime control more rapidly than those undergoing radical prostatectomy, and stress urinary incontinence is rarely an issue. This finding is likely a consequence of the lower voiding and resting pressures within a reservoir constructed of detubularized bowel compared to an intact bladder.3, 12 On the other hand, nocturnal enuresis is an unusual phenomenon after radical prostatectomy but it occurred at least to some extent in 29% of our patients, although only 16% wore a pad. The putative explanation is that the loss of normal neural feedback from an intact bladder does not permit reflexive tightening of the sphincter when bladder filling occurs during sleep.13 At any rate 71% of our patients were completely dry day and night, and only one sought additional treatment (collagen injection) because of problematic leakage. The rates of daytime incontinence in our series are lower than in comparable reports.7, 14 We used the same technique for dissection of the prostatic apex during cystoprostatectomy
TABLE 3. Orthotopic urinary reconstruction continence All pts. (100): Excellent Good Fair Poor Men (84): Excellent Good Fair Poor Women (16): Excellent Good Fair Poor
No. Daytime (%)
No. Nighttime (%)
93 (93) 7 (7) — —
71 (71) 11 (11) 15 (15) 3 (3)
79 (94) 5 (6) — —
58 (69) 10 (12) 14 (17) 2 (2)
14 (87) 2 (13) — —
13 (81) 1 (6) 1 (6) 1 (6)
58
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER
as for radical prostatectomy. In women care was taken to avoid excessive periurethral dissection but no suspension of the vaginal vault or anterior urethropexy was performed. A nerve sparing procedure was not attempted in women. In addition, it has been our policy to create a reservoir with a capacity of at least 200 cc on the operating room table, which is somewhat larger than many other reported techniques and may account partially for our results.7 A possible consequence of excessive capacity is inadequate emptying. However, self-catheterization was required by only 8% of our patients. All others are able to empty adequately with the Valsalva maneuver or by the Crede´ method in a few cases. It is important for patients to avoid chronic over distention of the reservoir, and most void every few hours because of a sensation of fullness in the reservoir. However, we also instruct patients to void every 3 to 4 hours. The duration of followup in our series is relatively short, and it is possible that in time more patients will have problems with emptying. Numerous techniques for construction of orthotopic reservoirs have been described,4 –7 and virtually all involve folding of detubularized colon or ileum to create a spherically shaped reservoir. Each technique or bowel segment may have some particular advantages but it becomes difficult to compare results between different series. Our study is unique in that the same surgeons used different techniques within a similar time frame, eliminating many of the variables in comparing results. We observed no statistically significant differences in voiding patterns among the various methods used for reservoir construction. It appears that excellent results can be achieved with virtually any of the techniques as long as there is adherence to certain principles. First of all, as with radical prostatectomy, continence is highly dependent on an appropriate anatomical dissection of the prostatic apex with preservation of the periurethral sphincter mechanism. In women excessive dissection of the urethra or disruption of the integrity of the pelvic floor support must be avoided.15 In addition, construction of an adequate capacity reservoir is important.5, 12 Although some degree of stretching of the reservoir occurs with time, we observed a higher rate of incontinence, particularly at night, earlier in our experience when a smaller reservoir capacity was achieved. Delayed decompensation with poor emptying may be observed occasionally but the need for intermittent self-catheterization by our patients is no higher than that in most other reported series. Maintenance of low intrareservoir pressures without coordinated peristaltic contractions is important and accomplished with virtually all of the described techniques by using detubularized bowel. Moreover, construction of a reservoir with a spherical configuration gives the greatest capacity and lowest wall tension for a given length of bowel.5, 12 Our results are important in that they document an excellent functional voiding pattern after radical cystectomy with orthotopic bladder reconstruction. For appropriately selected patients continent urinary reconstruction can offer an improved quality of life compared to an abdominal stoma. Our experience with the various procedures within a single institution by the same surgeons allowed a valid comparison of techniques. The comparable results among various methods underscore the significance of maintaining certain principles common to all techniques in achieving the desired outcome. CONCLUSIONS
Excellent functional voiding outcomes are obtained with radical cystectomy and orthotopic bladder reconstruction. Daytime leakage is rare and minimal nocturnal incontinence occurs in a small percentage of patients. Comparable results can be achieved with use of either large bowel or ileum and with various described methods of bowel folding as long as
principles of preservation of the periurethral sphincter muscle, and construction of an adequate capacity and low pressure reservoir are maintained. REFERENCES
1. Weijerman, P. C., Schurmans, J. R., Hop, W. C. et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology, 51: 51, 1998. 2. Benson, M. C., Slawin, K. M., Wechsler, M. H. et al: Analysis of continent versus standard urinary diversion. Br J Urol, 69: 156, 1992. 3. Gburek, B. M., Lieber, M. M. and Blute, M. L.: Comparison of studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. J Urol, 160: 721, 1998. 4. Reddy, P. K.: The colonic bladder. Urol Clin North Am, 18: 609, 1991. 5. Thu¨roff, J. W., Alken, P., Riedmiller, H. et al: 100 cases of Mainz pouch: continuing experience and evolution. J Urol, 140: 283, 1988. 6. Hautmann, R. E., Miller, K., Steiner, U. et al: The ileal neobladder: 6 years experience with more than 200 patients. J Urol, 150: 40, 1993. 7. Studer, U. E., Danuser, H., Merz, V. W. et al: Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol, 154: 49, 1995. 8. Elmajian, D. A., Stein, J. P., Esrig, D. et al: The Kock ileal neobladder: updated experience in 295 male patients. J Urol, 156: 920, 1996. 9. Pagano, F., Artibani, W., Aragona, F. et al: Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management. Arch Urol Esp, 50: 785, 1997. 10. Sullivan, L. D., Chow, V. D., Ko, D. S. et al: An evaluation of quality of life in patients with continent urinary diversions after cystectomy. Br J Urol, 81: 699, 1998. 11. Schlegel, P. N. and Walsh, P. C.: Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function. J Urol, 138: 1402, 1987. 12. Hinman, F., Jr.: Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol, 139: 519, 1988. 13. Jakobsen, H., Steven, K., Stigsby, B. et al: Pathogenesis of nocturnal urinary incontinence after ileocaecal bladder replacement. Continuous measurement of urethral closure pressure during sleep. Br J Urol, 59: 148, 1987. 14. Stein, J. P., Lieskovsky, G., Ginsberg, D. A. et al: The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique. J Urol, 159: 1836, 1998. 15. Hautmann, R. E., Paiss, T. and de Petriconi, R.: The ileal neobladder in women: 9 years of experience with 18 patients. J Urol, 155: 76, 1996. EDITORIAL COMMENT The authors report on the functional voiding outcome (patient interview and chart review) of 100 consecutive patients, including 16 women, undergoing cystectomy and orthotopic neobladder with 5 different techniques during a 5-year period with a mean followup of 2 years (range 6 to 66). Most reservoirs were made of ileum (84 of 100 cases). They explain their excellent results, that is all patients dry during the day, 71% dry at night and 8% dry on intermittent selfcatheterization, by the size of the reservoir initially created (greater than 200 ml.). This article comes from an excellent idea, namely assessing patient satisfaction with functional voiding outcome after different types of orthotopic neobladders. The main flaw of the study is its retrospective nature. Only patient interviews (obtained how long after the surgery and by whom?) and chart reviews were compiled to give a sense of overall “excellent” functional voiding outcome. Surprisingly, continence data are provided (table 3) but voiding parameters are not. The point made about all techniques faring equally well (only 2 cases of sigmoid colon) is arguable in the absence of objective outcomes, such as diaries indicating voided volumes, flow, residuals, and median and mean duration of followup for each group. For such an outcome study a validated questionnaire should be used, and a third party examiner or investigator should be charged with assessing the real degree of patient satisfaction. The aforementioned outcome variables should have been considered to avoid the subjectivity of the term “excellent”.
VOIDING OUTCOMES AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER A minimum long-term followup of 2 years might have given more credibility to the data since initial results in general tend to appear more favorable than long-term data as acknowledged by the authors in their discussion. Some specific information should have been provided on the subgroup of 16 women. Table 2 indicates that at least 2 are on intermittent self-catheterization, implying either hypercontinence or secondary cystocele. This observation is consistent with other series in the literature. Although the authors state that no secondary pouch infection or metabolic changes were observed there is no information on how frequently and by what means these factors were evaluated. It is clear that in the mind of the authors urinary control equates with patient satisfaction. Other dimensions of quality of life should be considered, unless they were addressed in the “detailed patient interview”, which should have been provided as an Appendix. Despite these obvious shortcomings, this article provides new and favorable information for the motivated patient desiring orthotopic neobladder reconstruction after cystectomy. Philippe Zimmern Division of Urology University of Texas Southwestern Medical School Dallas, Texas
59
REPLY BY AUTHORS Cancer control is the most important outcome measure after radical cystectomy for bladder cancer but seemingly is unaffected by the method of urinary reconstruction. Radical cystectomy is a formidable procedure with the potential for significant morbidity or even mortality postoperatively. However, we have performed radical cystectomy in more than 260 consecutive patients with no perioperative mortality who were discharged home a median of 6 days postoperatively. Therefore, it is appropriate to focus on quality of life measures related to urinary reconstruction. Urinary control is only 1 measure which contributes to patient satisfaction with an orthotopic neobladder but it is important. Other aspects of the functional voiding pattern are also presented in our report, such as voiding frequency, failure to empty the reservoir adequately and metabolic or infectious complications. Our review is a focused analysis of the functional voiding pattern after orthotopic neobladder but this is only 1 aspect of the parameters which contribute to quality of life. We believe that several surgical principles contribute to our results, and reservoir size is only 1 of them. With adherence to principles and performance of surgical technique, comparable results can be achieved with a number of methods of reservoir construction.