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Functional outcome and complications following ileal neobladder reconstruction in male patients without tumor recurrence. More than 35 years of experience from a single center

  • Richard E Hautmann 1,
  • Björn Volkmer 2,
  • Günther Egghart 3,
  • Detlef Frohneberg 4,
  • Hans-Werner Gottfried 5,
  • Jürgen Gschwend 6,
  • Robert Hefty 7,
  • Klaus Kleinschmidt 8,
  • Rainer Küfer 9,
  • Kurt Miller 10,
  • Robert de Petriconi 1,
  • Jörg Simon 11,
  • Ulrich Wenderoth 7
1 Department of Urology, University of Ulm, Neu-Ulm, Germany 2 Department of Urology, Klinikum Kassel, Kassel, Germany 3 Department of Urology, Kreiskrankenhaus Sigmaringen, Sigmaringen, Germany 4 Department of Urology, Klinikum Karlsruhe, Karlsruhe, Germany 5 Department of Urology, Evangelisches Krankenhaus, Göttingen-Weende, Germany 6 Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany 7 Department of Urology, Klinikum Heidenheim, Heidenheim, Germany 8 Department of Urology Helios Dr.-Horst-Schmidt Kliniken,Wiesbaden, Germany 9 Department of Urology, Klinik am Eichert Göppingen, Göppingen, Germany 10 Department of Urology, Charité University Berlin, Berlin, Germany 11 Department of Urology, Ortenau Klinikum Offenburg, Offenburg, Germany

Publication: Journal of Urology, August 2020

Purpose

There is a lack of data on true long term functional outcome of orthotopic bladder substitution. The primary objective was, to report our 35 year clinical experience.

Material and Methods

Since October 1985 259 male patients from a large single center radical cystectomy series with complete follow up of >60 months (median 121, range 60-267) without recurrence, irradiation or undiversion, that might have affected the functional outcome, were included.

Results

Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. 87% of patients voided spontaneously and residual free. This rate decreased with increasing age at the time of surgery (< 50y: 94%, 70y+: 82%). Overall day/night time continence rates were 90%/82%, respectively. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5y) to 19% (25y). Patients with a follow up of >20 years had the lowest rate of residual urine and CIC (0.0%) as well as use of >1 pad at day/night time (6.3%/12.5%), and mucus obstruction (0,0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (X2 11.227, p<0.005), even when the younger age at the time of surgery (<60y) was related to higher rates of surgical complications (X2 6.80,p<0.05).

Conclusions

The ileal neobladder represents an excellent long term option for urinary diversion with an acceptable complication rate.

Expert's summary

By Dr. Marco Moschini

Radical cystoprostatectomy with orthotopic bladder substitution performed by expert surgeons in referral centers is associated with excellent functional outcomes. These data are extremely important to understand functional and metabolic outcomes in our patients and to fully explain them expectations and risks in counseling the chose of the right urinary diversion. 

Expert's comment

In this retrospective single center study, authors evaluate long term functional outcome of orthotopic bladder substitution in male bladder cancer patients treated with radical cystectomy with orthotopic substitution. Since October 1985, 259 male patients were treated with a complete follow up of a minimum of 60 months. Authors of the study selected only patients without a recurrence. Median age of treated patients were 63 years, while the median age of the survey was 75. The majority of patients treated had organ confined disease without lymph node metastases. A serum creatinine higher than 2.0 mg/dl was considered as a contraindication of orthotopic bladder substitution and non of the patients included had a preoperative serum creatinine higher than 2.0 mg/dl. Considering urinary function, 87% of patients voided spontaneously and residual free. For patients younger than 50 years of age at the time of surgery, this rate increased to 94%. Indications and history of clean intermittent chateterization were, occasional mucus obstruction ( in only 3 men), before bedtime to reduce nocturia, residual urine >200 ml after spontaneous voiding in 5 patients and hyperincontinence needing regular catheterization in 8 patients. Daytime/night time continence rates of the 259 patients were 90 % and 82 %, respectively. During day time 185/259 patients were pad free, while 47 used a pad for safety. 25 patients used ≥ 2 pads during day time.

The use of bicarbonate was at 51% at 5 years. Patients with a follow up of 20 years or more had the lowest rate of residual urine and mucus obstruction. One patients developed end stage renal failure with hemodialysis.