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BJU International Jan 2014The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate... (Review)
Review
CONTEXT
The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.
OBJECTIVE
To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma.
EVIDENCE ACQUISITION
A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper.
EVIDENCE SYNTHESIS
Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option.
CONCLUSIONS
Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.
Topics: Cystectomy; Female; Humans; Male; Patient Selection; Peer Review; Postoperative Complications; Quality of Life; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion; Urinary Reservoirs, Continent
PubMed: 24330062
DOI: 10.1111/bju.12121 -
JAMA Jun 2022Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial.
IMPORTANCE
Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.
OBJECTIVES
To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.
INTERVENTIONS
Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).
MAIN OUTCOMES AND MEASURES
The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.
RESULTS
Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).
CONCLUSIONS AND RELEVANCE
Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.
TRIAL REGISTRATION
ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410.
Topics: Aged; Cystectomy; Female; Humans; Male; Morbidity; Neoplasm Recurrence, Local; Postoperative Complications; Quality of Life; Retrospective Studies; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 35569079
DOI: 10.1001/jama.2022.7393 -
Archivos Espanoles de Urologia Apr 2019It is well known that RARC with intracorporeal diversion is being increasingly performed worldwide. In this article, we review the current situation of the... (Review)
Review
OBJECTIVE
It is well known that RARC with intracorporeal diversion is being increasingly performed worldwide. In this article, we review the current situation of the intracorporeal neobladder.
METHODS
We discuss the principles of intracorporeal orhotopic diversion, focusing on the most relevant: The Karolinska-modified Studer neobladder, the University of Southern California-modified Studer neobladder. The pyramid pouch and the modified Y-shaped orthotopic neobladder. We also compare functional and perioperative outcomes from our series and the available studies regarding RARC and intracorporeal orthotopic diversion. RESULTS: Review of existing literature suggests that RARC with totally intracorporeal neobladder, in some cases, has improved operative, postoperative, and functional outcomes, becoming a safe and feasible alternative to ORC.
CONCLUSIONS
The results from the intraorporeal neobladders series appear to be promising, but high-quality randomized controlled trials comparing to ICUD to ECUD should be performed in order to define the advantages and disadvantages of totally intracorporeal urinary diversion and its future role in the treatment of invasive bladder cancer.
Topics: Cystectomy; Humans; Randomized Controlled Trials as Topic; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 30945658
DOI: No ID Found -
International Braz J Urol : Official... 2022A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms... (Review)
Review
PURPOSE
A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms of perioperative, functional, and oncological outcomes of high-risk elderly patients treated with radical cystectomy (RC). Protocol Registration: PROSPERO ID CRD42020168851.
MATERIALS AND METHODS
A systematic review, according to the PRISMA Statement, was performed. Search through the Medline, Embase, Scopus, Scielo, Lilacs, and Cochrane Database until July 2020.
RESULTS
The literature search yielded 2,883 citations and were selected eight studies, including 1096 patients. A total of 707 patients underwent IC and 389 CU. Surgical procedures and outcomes, complications, mortality, and quality of life were analyzed.
CONCLUSIONS
CU seems to be a safe alternative for the elderly and more frail patients. It is associated with faster surgery, less blood loss, lower transfusion rates, a lower necessity of intensive care, and shorter hospital stay. According to most studies, complications are less frequent after CU, even though mortality rates are similar. Studies with long-term follow up are awaited.
Topics: Aged; Cystectomy; Humans; Quality of Life; Ureterostomy; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 33861058
DOI: 10.1590/S1677-5538.IBJU.2020.0892 -
Deutsches Arzteblatt International Sep 2012Bladder cancer is not a rare disease: In 2010, there were more than 70 000 affected patients in the United States. Radical cystectomy for the treatment of muscle... (Review)
Review
BACKGROUND
Bladder cancer is not a rare disease: In 2010, there were more than 70 000 affected patients in the United States. Radical cystectomy for the treatment of muscle invasive bladder cancer necessitates urinary diversion.
METHODS
We present the current options for urinary diversion and their different indications on the basis of a selective search for pertinent literature in PubMed and our own clinical experience.
RESULTS
When bladder cancer is treated with curative intent, continence-preserving orthotopic urinary bladder replacement is preferred. For heterotopic urinary bladder replacement, a reservoir is fashioned from an ileal or ileocecal segment. Urine is diverted to the rectum by way of the sigmoid colon. When bladder cancer is treated with palliative intent, non-continence-preserving cutaneous urinary diversion is usually performed: The creation either of a renal-cutaneous fistula or a self-retaining ureteral stent is a purely palliative procedure. In these interventions, the resorptive surface of the bowel segment used can no longer play its original physiological role in the gastrointestinal tract, even though its absorptive and secretory functions are still intact. This has metabolic consequences, because the diverted urine here comes into contact with a large area of bowel epithelium. Early preventive treatment must be provided against potentially serious complications such as metabolic acidosis and loss of bone density. The resection of ileal segments can also lead to malabsorption. The risk of secondary malignancy is elevated after either continence-preserving anal urinary diversion (>2%) or bladder augmentation (>1%).
CONCLUSION
There are four options for urinary diversion after cystectomy that can be performed when surgery is performed with either curative or palliative intent. There are also a number of purely palliative interventions.
Topics: Cystectomy; Humans; Palliative Care; Postoperative Complications; Urinary Bladder Neoplasms; Urinary Diversion; Urinary Reservoirs, Continent
PubMed: 23093992
DOI: 10.3238/arztebl.2012.0617 -
International Journal of Gynecological... Jan 2021Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few... (Review)
Review
Pelvic exenteration combines multiple organ resections and functional reconstruction. Many techniques have been described for urinary reconstruction, although only a few are routinely used. The aim of this review is to focus beyond the technical aspects and the advantages and disadvantages of each technique, and to include a critical analysis of continent techniques in the gynecologic and urologic literature. Selecting a technique for urinary reconstruction must take into account the constraints entailed by the natural history of the disease, patient characteristics, healthcare institution, and surgeon experience. In gynecologic oncology, the Bricker ileal conduit is the most commonly employed diversion, followed by the self-catheterizable pouch and orthotopic bladder replacement. Continent and non-continent diversions present similar immediate and long-term complication rates, including lower tract urinary infections and pyelonephritis (5-50%), ureteral stricture (3-27%), urolithiasis (5-25%), urinary fistula (5%), and more rarely, vitamin B deficiency and metabolic acidosis. Urinary incontinence for the ileal orthotopic neobladder (50%), stoma-related complications for the Bricker ileal conduit (24%), difficulty with self-catheterization (18%) for the continent pouch, and induction of secondary malignancy for the ureterosigmoidostomy (3%) are the most relevant technique-related complications following urinary diversion. The self-catheterizable pouch and orthotopic bladder require a longer learning curve from the surgical team and demand adaptation from the patient compared with the ileal conduit. Quality of life between different techniques remains controversial, although it would seem that young patients may benefit from continent diversions. We consider that centralization of pelvic exenteration in referral centers is crucial to optimize the oncologic and functional outcomes of complex ablative reconstructive surgery.
Topics: Female; Genital Neoplasms, Female; Humans; Medical Oncology; Pelvic Exenteration; Urinary Diversion
PubMed: 33229410
DOI: 10.1136/ijgc-2020-002015 -
Archivos Espanoles de Urologia Apr 2019There has been growing interest in intracorporeal techniques to urinary diversion during cystectomy in the modern area. There is little high-quality evidence that this... (Review)
Review
There has been growing interest in intracorporeal techniques to urinary diversion during cystectomy in the modern area. There is little high-quality evidence that this technique is superior to extracorporeal diversion in patients who are obtaining an orthotopic intracorporeal neobladder urinary diversion. This study describes the proposed advantages and disadvantages of intracorporeal orthotopic neobladder urinary diversion and expert opinion on preference. METHODS: We reviewed the literature for all studies discussing the outcomes and advantages of intracorporeal orthotopic neobladder urinary diversion, including those comparing the intracorporeal and extracorporeal approach. The studies were reviewed and these findings were summarized based on categories of the proposed advantages and disadvantages of the intracorporeal approach. We provided an assessment of the claims made in favor of the intracorporeal approach and discussed advantages of the extracorporeal approach that may persuade even the most experienced robotic surgeons to lean away from the former. RESULTS AND CONCLUSIONS: Herein we review the studies that propose advantages of the intracorporeal diversion, as well as the studies that do not demonstrate any advantage to this approach. Some of the proposedadvantages addressed include decreased stricture rate, lower complications and shorter hospitalization. Furthermore, we address the issues of the steep learningcurve and the impact on resident education. We conclude that the proposed benefits of an intracorporeal approach to urinary diversion are not substantiated and it is the preference of the authors to primarily perform extracorporeal urinary diversions.
Topics: Cystectomy; Humans; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 30945659
DOI: No ID Found -
Scientific Reports Aug 2021The use of an ileal segment is a standard method for urinary diversion after radical cystectomy. Unfortunately, utilization of this method can lead to numerous surgical...
The use of an ileal segment is a standard method for urinary diversion after radical cystectomy. Unfortunately, utilization of this method can lead to numerous surgical and metabolic complications. This study aimed to assess the tissue-engineered artificial conduit for urinary diversion in a porcine model. Tissue-engineered tubular polypropylene mesh scaffolds were used for the right ureter incontinent urostomy model. Eighteen male pigs were divided into three equal groups: Group 1 (control ureterocutaneostomy), Group 2 (the right ureter-artificial conduit-skin anastomoses), and Group 3 (4 weeks before urostomy reconstruction, the artificial conduit was implanted between abdomen muscles). Follow-up was 6 months. Computed tomography, ultrasound examination, and pyelogram were used to confirm the patency of created diversions. Morphological and histological analyses were used to evaluate the tissue-engineered urinary diversion. All animals survived the experimental procedures and follow-up. The longest average patency was observed in the 3rd Group (15.8 weeks) compared to the 2nd Group (10 weeks) and the 1st Group (5.8 weeks). The implant's remnants created a retroperitoneal post-inflammation tunnel confirmed by computed tomography and histological evaluation, which constitutes urostomy. The simultaneous urinary diversion using a tissue-engineered scaffold connected directly with the skin is inappropriate for clinical application.
Topics: Animals; Male; Swine; Tissue Engineering; Tissue Scaffolds; Ureter; Urinary Bladder; Urinary Diversion
PubMed: 34408168
DOI: 10.1038/s41598-021-94613-7 -
Minerva Urology and Nephrology Jun 2022Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about...
INTRODUCTION
Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. Therefore, clear, and comprehensive clinical guidelines based on evidence-based data and best practice are needed. The aim of this article was to elaborate guidelines for practice management of urinary stomas in adults.
EVIDENCE ACQUISITION
Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation," "stoma creation," "stoma complications," "stoma care" and "stoma reversal." The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.
EVIDENCE SYNTHESIS
After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.
CONCLUSIONS
These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.
Topics: Adult; Consensus; Humans; Interdisciplinary Studies; Italy; Surgical Stomas; Urinary Diversion
PubMed: 34114787
DOI: 10.23736/S2724-6051.21.04379-2 -
Chirurgia (Bucharest, Romania : 1990) Feb 2023Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of...
Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of the MIBC has been observed, from open surgery to minimal invasive surgery. Nowadays, in the majority of tertiary urologic centers, robotic radical cystectomy with intracorporeal urinary diversion represents the standard surgical approach. The aim of the current study is to describe in detail the surgical steps of the robotic radical cystectomy and the reconstruction of the urinary diversion and to present our experience. From the surgical point of view, the most important principles which should guide the surgeon when performing this procedure are: 1. Good working place and access both to the pelvis and abdomen and use of the "technique of spaces" 2. Respect the oncological principles of the surgery with attention to the margin resection and limitation of the risk of tumour spillage; 3. Attention to both the ureter and bowel manipulation in order to avoid grasping lesions; 4. High care in realisation of the uretero-ileal anastomosis so that good long term functional results are achieved. We analyzed our database of 213 patients diagnosed with muscle invasive bladder cancer who underwent minimally invasive radical cystectomy (laparoscopic and robotic approaches) between January 2010 and December 2022. We identified 25 patients for whom the robotic approach was used to perform the surgery. Despite being one of the most challenging urologic surgical procedures, with careful preparation and training, the surgeon is able to achieve the maximum oncological and functional results by performing robotic radical cystectomy with intracorporeal urinary.
Topics: Humans; Cystectomy; Robotic Surgical Procedures; Treatment Outcome; Urinary Diversion; Urinary Bladder Neoplasms
PubMed: 36913419
DOI: 10.21614/chirurgia.2834