Original Paper
Urologia Internationalis
Received: June 26, 2013 Accepted after revision: October 7, 2013 Published online: April 9, 2014
Urol Int 2014;93:43–48 DOI: 10.1159/000356283
Modified S-Ileal Neobladder for Continent Urinary Diversion: Functional and Urodynamic Results after 20 Years of Follow-Up Athanasios E. Dellis a Athanasios G. Papatsoris b Andreas A. Skolarikos b Ioannis M. Varkarakis b Charalambos N. Deliveliotis b a
2nd Department of Surgery, Aretaieion Hospital, University of Athens, and b 2nd Department of Urology, Sismanogleion Hospital, University of Athens, Athens, Greece
Abstract Objective: To report continence and urodynamic findings after radical cystectomy and urinary diversion with modified S-ileal neobladder between January 1993 and January 2013. Patients and Methods: 181 patients were enrolled. Continence status, reservoir sensation, compliance, capacity and activity were assessed. Results: Daytime continence was reported by 88.0, 98.4 and 99.2%, while nighttime continence was reported by 70.2, 94.0 and 95.8% of our patients at 6 months, 5 years and 20 years, respectively. Enterocystometric capacity and maximum reservoir pressure were 366 vs. 405 ml and 502 ml, and 29 vs. 18 and 11 cm H2O, at 6 months, 5 years and 20 years, respectively. Median post-void residual urine volume was 32 ml at 6 months, 50 ml at 5 years and 120 ml at 20 years. Conclusions: The modified S-ileal neobladder technique has a very good long-lasting functional outcome, with high day- and nighttime continence levels as well as high acceptability rates from our patients. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0043$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Since the pioneering studies of Couvelaire [1] as well as Lilien and Camey [2] in urinary diversion with the use of non-detubularized high-pressure bowel segments, several techniques of orthotopic bladder substitution have been studied. The main objective in orthotopic bladder substitution, apart from good oncologic outcome, is the recovery of normal lower urinary tract function. In 1993, we were the first to develop the ‘modified S-ileal neobladder’ (fig. 1) technique where a shorter (mean length 40 cm) ileal segment was used in comparison with previously described ileal neobladders. In our modified technique the ileal segment is completely detubularized and folded in an S configuration, with a mean length of each arm of up to 15 cm, without creating a nipple mechanism [3]. Nearly a decade ago we published our results after a 5-year follow-up [4], and in this article we present our functional and urodynamic results after a follow-up of 20 years.
Athanasios E. Dellis, MD, PhD, FEBU 2nd Department of Surgery, Aretaieion Hospital University of Athens, 76, Vas. Sofias Ave. GR–11528 Athens (Greece) E-Mail aedellis @ gmail.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/30/2015 9:09:08 AM
Key Words Continent urinary reservoirs · Urinary diversion · Urinary incontinence · Urodynamics
Table 1. Patient demographics
After institutional board review approval, 208 patients (201 men and 7 women) underwent radical cystectomy and creation of a modified S-ileal neobladder and were included in this prospective study, from January 1993 to January 2013. The patients’ demographic characteristics are detailed in table 1. All patients were diagnosed with invasive transitional cell carcinoma of the bladder. Mean patient age at surgery was 61.5 years (range 52– 70). Patients older than 70 years were not considered suitable for orthotopic bladder substitution. None of the patients underwent neoadjuvant chemotherapy. Postoperatively, patients were evaluated at 3-month intervals for year 1, at 6-month intervals for years 2 and 3, and annually thereafter. Postoperative evaluation included clinical examination, complete blood count, serum creatinine and electrolytes, blood gas analysis, urinalysis and ultrasonography of the kidneys and neobladder. The follow-up ranged from 48 to 235 months (mean 162.4). Urodynamic measurements were performed using the Jupiter 8000 machine (Wiest Urodynamics, World of Medicine AG, Berlin, Germany). 51 patients dropped out and were lost to follow-up. 14 patients died because of bladder cancer progression (3 patients after 1 year, 5 patients after 3 years and 6 patients after 5 years of follow-up), while 24 patients died from other causes, unrelated to bladder cancer. At each postoperative follow-up visit, a urologist other than the surgeon who had performed radical cystectomy and orthotopic bladder substitution interviewed each patient in order to specify voiding behavior by means of questionnaires and frequency-volume charts. The parameters tested included day- and nighttime continence, voiding frequency, voiding duration, preferred voiding position (sitting versus standing), ease of voiding with or without simultaneous defecation, stress incontinence and quality of life. Specific definitions were given for day- and nighttime continence. Daytime continence was defined as the status where the patient was completely dry without use of any pad, while in nighttime continence the patient was completely dry with two or fewer voids per night. Satisfactory continence was defined when no more than one pad was required during the day or night. All other cases were defined as incontinent. Urodynamic studies such as filling cystometry and residual urine volume measurement were performed 6 and 12 months postoperatively, once yearly until the 5th year and then every 5 years until the end of our follow-up period. At each urodynamic study visit, urethral catheterization with a 10-Fr triple lumen catheter was performed, followed by assessment of post-void residual urine volume. A 10-Fr balloon catheter placed in the rectum was used to record abdominal pressure. Reservoir pressure was calculated by subtracting abdominal pressure from total reservoir pressure. Medium fill cystometry was then performed with the patient supine using 37 ° C saline at slow filling rates of ≤30 ml/min to eliminate involuntary reservoir muscle activity that produces uncharacteristic symptoms for patients. Volume was recorded at initial desire to void and at initial contraction. Maximum cystometric reservoir capacity was documented as the volume at which the patient had a sensation of fullness. Reservoir pressure with the reservoir empty, half filled and at maximum cystometric capacity was recorded, as was the amplitude of the maximum contraction pressure. The urodynamic data obtained were subdivided into groups from 6 months to 20 years according
44
Urol Int 2014;93:43–48 DOI: 10.1159/000356283
Male/female Mean age, years (range) pT1G3 pT2G1 pT2G2 pT2G3 pT3b Mean follow-up, months (range)
201/7 61.5 (52 – 70) 16 42 139 8 3 162.4 (48 – 235)
to time elapsed since operation. Methods, definitions and units conformed to the standards recommended by the International Continence Society [5]. Post-void residual urine volumes >120 ml were managed by clean intermittent self-catheterization with a 14-Fr catheter.
Results
Of the 181 patients (179 men and 2 women) studied, 159 (87.8%) were daytime continent at 6 months, while 98.4% (125 out of 127) of our patients reported daytime continence at 5-year follow-up and 99.2% (118 out of 119) remained continent during the follow-up period. The mean time postoperatively to achieve satisfactory, but not complete, daytime continence was 6 months. Of the 22 incontinent patients (12.2%), 16 used one small pad daily, while the other 6, including both women of our study, had to use two small pads daily. Furthermore, 70.2% of our patients (127 of 181) reported nighttime continence awakening up to two times per night to void at 6 months, with 94.5% (120 of 127) reporting continence during the night at 5 years and 95.8% (114 of 119) at the end of follow-up. The great majority (81.5%, 97 of 119) of our patients used Credé’s maneuver when sitting on the toilet in order to empty their neobladders, while the rest of them (22 of 119) voided spontaneously with abdominal straining. All of our patients reported improvement in voiding overtime. After 6 months, 70.2% (127 of 181) of our patients managed to void every 3 h or longer, while 4.4% (8 of 181) could not postpone voiding for more than 2 h during the day. During the night at 6 months, 61.3% (111 of 181) patients voided every 3 h or longer, while 3.3% (6 of 181) reported voiding every 2 h or less. After 5 years, during the day, 94.5% (120 of 127) of patients voided every 3 h or longer, with improvement in voiding during the night as well: 89.0% (113 of 127) of patients had 3 h intervals or more between voiding. At the end of our followDellis /Papatsoris /Skolarikos /Varkarakis / Deliveliotis
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/30/2015 9:09:08 AM
Patients and Methods
Table 2. Voiding patterns
Voiding frequency Daytime intervals ≥3 h 2–3 h
Urologia Internationalis
Received: June 26, 2013 Accepted after revision: October 7, 2013 Published online: April 9, 2014
Urol Int 2014;93:43–48 DOI: 10.1159/000356283
Modified S-Ileal Neobladder for Continent Urinary Diversion: Functional and Urodynamic Results after 20 Years of Follow-Up Athanasios E. Dellis a Athanasios G. Papatsoris b Andreas A. Skolarikos b Ioannis M. Varkarakis b Charalambos N. Deliveliotis b a
2nd Department of Surgery, Aretaieion Hospital, University of Athens, and b 2nd Department of Urology, Sismanogleion Hospital, University of Athens, Athens, Greece
Abstract Objective: To report continence and urodynamic findings after radical cystectomy and urinary diversion with modified S-ileal neobladder between January 1993 and January 2013. Patients and Methods: 181 patients were enrolled. Continence status, reservoir sensation, compliance, capacity and activity were assessed. Results: Daytime continence was reported by 88.0, 98.4 and 99.2%, while nighttime continence was reported by 70.2, 94.0 and 95.8% of our patients at 6 months, 5 years and 20 years, respectively. Enterocystometric capacity and maximum reservoir pressure were 366 vs. 405 ml and 502 ml, and 29 vs. 18 and 11 cm H2O, at 6 months, 5 years and 20 years, respectively. Median post-void residual urine volume was 32 ml at 6 months, 50 ml at 5 years and 120 ml at 20 years. Conclusions: The modified S-ileal neobladder technique has a very good long-lasting functional outcome, with high day- and nighttime continence levels as well as high acceptability rates from our patients. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0042–1138/14/0931–0043$39.50/0 E-Mail [email protected] www.karger.com/uin
Introduction
Since the pioneering studies of Couvelaire [1] as well as Lilien and Camey [2] in urinary diversion with the use of non-detubularized high-pressure bowel segments, several techniques of orthotopic bladder substitution have been studied. The main objective in orthotopic bladder substitution, apart from good oncologic outcome, is the recovery of normal lower urinary tract function. In 1993, we were the first to develop the ‘modified S-ileal neobladder’ (fig. 1) technique where a shorter (mean length 40 cm) ileal segment was used in comparison with previously described ileal neobladders. In our modified technique the ileal segment is completely detubularized and folded in an S configuration, with a mean length of each arm of up to 15 cm, without creating a nipple mechanism [3]. Nearly a decade ago we published our results after a 5-year follow-up [4], and in this article we present our functional and urodynamic results after a follow-up of 20 years.
Athanasios E. Dellis, MD, PhD, FEBU 2nd Department of Surgery, Aretaieion Hospital University of Athens, 76, Vas. Sofias Ave. GR–11528 Athens (Greece) E-Mail aedellis @ gmail.com
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/30/2015 9:09:08 AM
Key Words Continent urinary reservoirs · Urinary diversion · Urinary incontinence · Urodynamics
Table 1. Patient demographics
After institutional board review approval, 208 patients (201 men and 7 women) underwent radical cystectomy and creation of a modified S-ileal neobladder and were included in this prospective study, from January 1993 to January 2013. The patients’ demographic characteristics are detailed in table 1. All patients were diagnosed with invasive transitional cell carcinoma of the bladder. Mean patient age at surgery was 61.5 years (range 52– 70). Patients older than 70 years were not considered suitable for orthotopic bladder substitution. None of the patients underwent neoadjuvant chemotherapy. Postoperatively, patients were evaluated at 3-month intervals for year 1, at 6-month intervals for years 2 and 3, and annually thereafter. Postoperative evaluation included clinical examination, complete blood count, serum creatinine and electrolytes, blood gas analysis, urinalysis and ultrasonography of the kidneys and neobladder. The follow-up ranged from 48 to 235 months (mean 162.4). Urodynamic measurements were performed using the Jupiter 8000 machine (Wiest Urodynamics, World of Medicine AG, Berlin, Germany). 51 patients dropped out and were lost to follow-up. 14 patients died because of bladder cancer progression (3 patients after 1 year, 5 patients after 3 years and 6 patients after 5 years of follow-up), while 24 patients died from other causes, unrelated to bladder cancer. At each postoperative follow-up visit, a urologist other than the surgeon who had performed radical cystectomy and orthotopic bladder substitution interviewed each patient in order to specify voiding behavior by means of questionnaires and frequency-volume charts. The parameters tested included day- and nighttime continence, voiding frequency, voiding duration, preferred voiding position (sitting versus standing), ease of voiding with or without simultaneous defecation, stress incontinence and quality of life. Specific definitions were given for day- and nighttime continence. Daytime continence was defined as the status where the patient was completely dry without use of any pad, while in nighttime continence the patient was completely dry with two or fewer voids per night. Satisfactory continence was defined when no more than one pad was required during the day or night. All other cases were defined as incontinent. Urodynamic studies such as filling cystometry and residual urine volume measurement were performed 6 and 12 months postoperatively, once yearly until the 5th year and then every 5 years until the end of our follow-up period. At each urodynamic study visit, urethral catheterization with a 10-Fr triple lumen catheter was performed, followed by assessment of post-void residual urine volume. A 10-Fr balloon catheter placed in the rectum was used to record abdominal pressure. Reservoir pressure was calculated by subtracting abdominal pressure from total reservoir pressure. Medium fill cystometry was then performed with the patient supine using 37 ° C saline at slow filling rates of ≤30 ml/min to eliminate involuntary reservoir muscle activity that produces uncharacteristic symptoms for patients. Volume was recorded at initial desire to void and at initial contraction. Maximum cystometric reservoir capacity was documented as the volume at which the patient had a sensation of fullness. Reservoir pressure with the reservoir empty, half filled and at maximum cystometric capacity was recorded, as was the amplitude of the maximum contraction pressure. The urodynamic data obtained were subdivided into groups from 6 months to 20 years according
44
Urol Int 2014;93:43–48 DOI: 10.1159/000356283
Male/female Mean age, years (range) pT1G3 pT2G1 pT2G2 pT2G3 pT3b Mean follow-up, months (range)
201/7 61.5 (52 – 70) 16 42 139 8 3 162.4 (48 – 235)
to time elapsed since operation. Methods, definitions and units conformed to the standards recommended by the International Continence Society [5]. Post-void residual urine volumes >120 ml were managed by clean intermittent self-catheterization with a 14-Fr catheter.
Results
Of the 181 patients (179 men and 2 women) studied, 159 (87.8%) were daytime continent at 6 months, while 98.4% (125 out of 127) of our patients reported daytime continence at 5-year follow-up and 99.2% (118 out of 119) remained continent during the follow-up period. The mean time postoperatively to achieve satisfactory, but not complete, daytime continence was 6 months. Of the 22 incontinent patients (12.2%), 16 used one small pad daily, while the other 6, including both women of our study, had to use two small pads daily. Furthermore, 70.2% of our patients (127 of 181) reported nighttime continence awakening up to two times per night to void at 6 months, with 94.5% (120 of 127) reporting continence during the night at 5 years and 95.8% (114 of 119) at the end of follow-up. The great majority (81.5%, 97 of 119) of our patients used Credé’s maneuver when sitting on the toilet in order to empty their neobladders, while the rest of them (22 of 119) voided spontaneously with abdominal straining. All of our patients reported improvement in voiding overtime. After 6 months, 70.2% (127 of 181) of our patients managed to void every 3 h or longer, while 4.4% (8 of 181) could not postpone voiding for more than 2 h during the day. During the night at 6 months, 61.3% (111 of 181) patients voided every 3 h or longer, while 3.3% (6 of 181) reported voiding every 2 h or less. After 5 years, during the day, 94.5% (120 of 127) of patients voided every 3 h or longer, with improvement in voiding during the night as well: 89.0% (113 of 127) of patients had 3 h intervals or more between voiding. At the end of our followDellis /Papatsoris /Skolarikos /Varkarakis / Deliveliotis
Downloaded by: UCSF Library & CKM 169.230.243.252 - 4/30/2015 9:09:08 AM
Patients and Methods
Table 2. Voiding patterns
Voiding frequency Daytime intervals ≥3 h 2–3 h
