Contemporary outcomes of patients undergoing robotic-assisted radical cystectomy:A comparative analysis between intracorporeal ileal conduit and neobladder urinary diversions

Objective We aimed to compare perioperative and oncologic outcomes for patients undergoing robotic-assisted radical cystectomy(RARC)with intracorporeal ileal conduit(IC)and neobladder(NB)urinary diversion.Methods Patients undergoing RARC with intracorporeal urinary diversion between January 2017 and January 2022 at the Icahn School of Medicine at Mount Sinai,New York,NY,USA were indexed.Baseline demographics,clinical characteristics,perioperative,and oncologic outcomes were analyzed.Survival was estimated with Kaplan-Meier plots.Results Of 261 patients(206[78.9%]male),190(72.8%)received IC while 71(27.2%)received NB diversion.Median age was greater in the IC group(71[interquartile range,IQR 65-78]years vs.64[IQR 59-67]years,p<0.001)and BMI was 26.6(IQR 23.2-30.4)kg/m^(2).IC group was more likely to have prior abdominal or pelvic radiation(15.8%vs.2.8%,p=0.014).American Association of Anesthesiologists scores were comparable between groups.The IC group had a higher proportion of patients with pathological tumor stage 2(pT2)tumors(34[17.9%]vs.10[14.1%],p=0.008)and pathological node stages pN2-N3(28[14.7%]vs.3[4.2%],p<0.001).The IC group had less median operative time(272[IQR 246-306]min vs.341[IQR 303-378]min,p<0.001)and estimated blood loss(250[150-500]mL vs.325[200-575]mL,p=0.002).Thirty-and 90-day complication rates were 44.4%and 50.2%,respectively,and comparable between groups.Clavien-Dindo grades 3-5 complications occurred in 27(10.3%)and 34(13.0%)patients within 30 and 90 days,respectively,with comparable rates between groups.Median follow-up was 324(IQR 167-552)days,and comparable between groups.Kaplan-Meier estimate for overall survival at 24 months was 89%for the IC cohort and 93%for the NB cohort(hazard ratio 1.23,95%confidence interval 1.05-2.42,p=0.02).Kaplan-Meier estimate for recurrence-free survival at 24 months was 74%for IC and 87%for NB(hazard ratio 1.81,95%confidence interval 0.82-4.04,p=0.10).Conclusion Patients undergoing intracorporeal IC urinary diversion had higher postoperative cancer stage,increased nodal involvement,similar complications outcomes,decreased overall survival,and similar recurrence-free survival compared to patients undergoing RARC with intracorporeal NB urinary diversion.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer(part 2).Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder

Objective:To review the most used intracorporeal orthotopic ileal neobladder(ICONB)after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives,including new consistent images.Methods:We performed a non-systematic review of the literature with the keywords“bladder cancer”,“urinary diversion”,“radical cystectomy”,and“neobladder”.Results:Forty studies were included in the analysis.The most frequent type of ICONB was the modified Studer“U”neobladder(70%)followed by the Hautmann“W”modified neobladder(7.5%),the“Y”neobladder(5%),and the Padua neobladder(5%).The operative time to perform a urinary diversion ranged from 124 to 553 min.The total estimated blood loss ranged from 200 to 900 mL.The rate of positive surgical margins ranged from 0%to 8.1%.Early minor and major complication rates ranged from 0%to 100%and from 0%to 33%,respectively.Late minor and major complication rates ranged from 0%to 70%and from 0%to 25%,respectively.Conclusion:The most frequent types of ICONB are Studer“U”neobladder,Hautmann“W”neobladder,“Y”neobladder,and the Padua neobladder.Randomized studies comparing the performance of the different types of ICONB,the performance in an intra or extracorporeal manner,or the performance of an ICONB versus ICIC are lacking in the literature.To this day,there are not sufficient quality data to determine the supremacy of one technique.This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects,operative and perioperative outcomes,and new consistent images of each technique.

Urinary Continence after Orthotopic Detubularized Ileocaecal Pouch Versus Ileal Neobladder:Does it Differ?

Objective:To compare both techniques of detubularized ileocaecal and ileal neobladder post radical cystectomy with regards to functional results in the form of continence(day and night)with the use of urodynamics(for assessment of voiding volume and pouch capacity).Methods:This is a prospective randomized clinical trial that was done at the National Cancer Institute,Cairo University from August 2016 and January 2018.Sixty-two patients presented with muscle invasive urinary bladder cancer and no history of urinary incontinence or urethral stricture were included in this study.All patients underwent preoperative cystoscopic examination.Radical cystectomy was done,and patients were divided into two groups according to the type of diversion.Group A included 31 patients with orthotopoic detubularized ileal neobladder and group B included 31 patients with orthotopic detubularized ileocaecal neobladder.Urodynamic studies were done to 27 patients in group A and 27 patients in group B at just 6 and 12 months postoperatively.Results:The mean age in group A was 59.2±8.0 while in group B was 57.8±6.6.In each group,we compared day and night continence in a period of 3 and 6 months.Postoperatively in group A,day continence after 3 months was 81.5% which improved to 96.3% after 6 months postoperatively with significant P-value(0.025).Night continence after 3 months was fair in 66.7%,unsatisfactory in 33.3% and 0% for good state which improved to 70% for fair state,18% unsatisfactory and 11% for good state after 6 months with significant P-value(0.035)while in group B,day continence after 3 months and 6 months postoperatively was 100% and night continence after 3 months was good in 0.0%,fair in 78.6% and unsatisfactory in 21.4% which improved to 10.7% for good state,85.7% for fair state and 3.6% for unsatisfactory after 6 months with significant P-value(0.005).Conclusion:There are no significant differences between detubularized ileocaecal and ileal neobladder in relation to continence.However,there is significant change in each type of diversion separately with time.

Laparoscopic radical cystectomy with orthotopic ileal neobladder in the female： report of 14 cases

Background Bladder carcinoma is the most common malignant urological tumor in China. We present our preliminary experience and results of laparoscopic radical cystectomy （LRC） with orthotopic ileal neobladder in female patients with bladder carcinoma. Methods From February 2003 to February 2008, 14 female patients with bladder carcinoma underwent LRC with orthotopic ileal neobladder. Nine of these patients underwent hysterectomy and ovariectomy, and the other 5 had preservation of the uterus and ovarian appendage. Standard bilateral pelvic lymphadenectomy was followed by radical cystectomy that was completed laparoscopically with hysterectomy and ovariectomy when needed. The tumor was removed by a 4-5 cm lower midline abdominal incision, followed by the construction of ileal neobladder and the extracorporeal anastomosis of ureter-neobladder. The neobladder was anastomosed to the urethral stump under a laparoscope. Results The mean operative time and blood loss in the 14 patients were 350.2 minutes and 349.8 ml, respectively. Postoperative complications included uretero-pouch anastomotic stricture in 1 patient and pouch-vaginal fistula in 1 patient. Follow-up time of all patients ranged from 3 to 60 months, and 12 patients were followed up for more than 6 months and achieved micturition in half a year. One patient had occasional day-time urinary incontinence and 2 had night-time incontinence. Two patients who had undergone hystectomy and ovariectomy had voiding difficulties after one year, which was treated by intermittent self-catheterization. The mean volume of the neobladder and the residual urine were 333.6 ml and 31.2 ml, respectively. Surgical margins were tumor free for all patients. One patient had bone metastasis and died 11 months after the operation. Conclusions LRC with orthotopic ileal neobladder in female patients is a technically feasible, safe and mini-invasive procedure with a low morbidity and acceptable neobladder function. Long-term follow-up is required to confirm the neobladder function and oncological outcomes.

Laparoscopic radical cystectomy with orthotopic ileal neobladder: report of 33 cases

Background The laparoscopic radical cystectomy (LRC) with orthotopic ileal neobladder is now applied to treat invasive bladder cancer, however, it has not been well codified and illustrated We describe in this paper a technique step by step that we have developed in 33 patients and achieved excellent results Methods The surgical procedure can be divided into eight steps: laparoscopic pelvic lymphadenectomy and mobilization of the distal ureters; exposing Denonvillier’s space and the posterior aspect of prostate; exposing retropubic space and anterior surface of the bladder; dividing the lateral pedicles of the bladder and the prostate; dividing the apex of the prostate; extracorporeal formation of the ileal pouch; extracorporeal implantation of the ureters; and laparoscopic urethra neobladder anastomosis This operation was performed in 33 patients, 29 males and 4 females, with muscle invasive bladder cancer between December 2002 and September 2004 Results The operating time was 5 5-8 5 hours with an average of 6 5 hours; the estimated blood loss was 200-1000 ml with an average of 460 ml The surgical margins of the bladder specimen were negative in all patients There was no evidence of local recurrence at follow up of 1-21 months in all the patients However lymph node metastases were found in one case at 9 months postoperatively Most of patients achieved urine control 1 to 3 months after surgery The daytime continence rate was 94% (31 cases) and nighttime continence rate was 88% (29 cases) Urodynamic evaluation was performed between 3 and 6 months postoperatively for all cases The mean value of neobladder capacity was (296±37) ml The mean value of maximum flow rate was (18 7±7 1) ml/s The mean residual urine volume was (32±19) ml In all cases, excretory urography at 1 to 2 months postoperatively demonstrated slightly dilated upper urinary tracts without ureteral obstruction, which resolved at follow up Cystography showed neobladders being similar in shapes to normal Two small ureteral nipples with intermittently efflux of urine were observed at cystoscopy in most patients Postoperative complications occurred in 6 of 33 patients (18%), including pouch leakage in 2 cases, pelvic infection in 1, partial small bowel obstruction in 2 and neobladder vaginal fistula in 1 Conclusions The LRC with orthotopic ileal neobladder is a feasible option for bladder cancer when radical cystectomy is indicated The extracorporeal formation of the ileal pouch and ureteral implantation through a small lower midline incision can simplify the complexity of the procedures, shorten the duration of surgery and reduce the medical expenses

Human adipose-derived mesenchymal stem cells accelerate decellularized neobladder regeneration

Decellularized natural bladder matrices(neobladders)represent an exciting means to regenerate the bladder following bladder cancer-associated cystectomy.In this study,we compare the evolution of decellularized matrices with recellularized matrices by seeding it with human adiposederived mesenchymal stem cells(ADSC)after implantation following partial cystectomy in rats.We discovered significant anatomical differences since 10 days after neobladder implantation with the ADSC-containing matrices promoting a significant recovery of mature p63-and cytokeratin 7-positive urothelium.We also discovered significantly induced expression of the vimentin mesoderm marker in the submucosal layer in ADSC-seeded matrices.Interestingly,we found a higher expression of smooth muscle actin in transversal and longitudinal smooth muscle layers with ADSC-seeded matrices.Furthermore,ADSC also showed increased vascularization and nerve innervation of the neobladder as determined by the distribution of CD31 and S100b reactivity,respectively.We believe that ADSC and their paracrine-acting pro-regenerative secretome within decellularized matrices represent an efficient bladder substitution strategy;however,we require a fuller understanding of the mechanisms involved before clinical studies can begin.

Hand-assisted-drawing-needle running suture with a curved needle： an effective technique to create a W-ileal neobladder

Background An important milestone in the area of urinary diversion was the advent of a series of orthotopic bladder substitution （OBS）. However, reconstruction of OBS by the traditional hand suture method （THSM） is a time-consuming process. Stapling techniques are considered to be inferior to hand-sewn methods. We report our experience and functional results in patients with W-ileal neobladder by a hand-assisted-drawing-needle running suture （HADNRS）. Methods Between April 1993 and December 2011, 347 patients （338 men and 9 women） aged 28-77 years （median age： 59 years） underwent radical cystectomy, followed by the creation of a modified W-ileal neobladder by HADNRS with a curved needle. A total of 347 （20 patients in 2003） were evaluated by urodynamic tests. Results The operative time ranged from 110 to 310 minutes （mean 148 minutes）, and the mean time of reconstruction by HADNRS, excluding ureterointestinal and ileouretral anastomosis, was （20.2±4.3） minutes. Histopathological analysis of removed specimens showed that 317 patients had transitional cell bladder carcinoma. Of these 317 patients, 19 also had squamous carcinoma and 13 had adenocarcinoma. Glandularis and prostate cancer occurred in 16 and 14 patients, respectively. Three patients （0.8%） had neobladder abdominal fistula. No other early complications or injury to the surgeon＇s hands occurred due to HADNRS. Of the 20 cases with urodynamic examinations in 2003, two suffered from daytime incontinence and six had nocturnal incontinence. The maximum capacity of the neobladder was （492.9±177.8） ml, and the maximum pressure within the reservoir at the end of filling was （32.1±8.6） cmH2O.Conclusion Reconstruction of W-ileal neobladder by HADNRS is effective and economical.

Orthotopic ileal neobladder similar to original bladder

Objective To report the surgical techniques and results of an 8-year follow-up study of 42 patients with a modified orthotopic ileal neobladder restoring normal anatomical relationship. Methods Total cystoprostatectomy was performed extraperitoneally. A 45-50 cm segment of the ileal loop was isolated, detubularized, and reconfigured into an “M”-shape to form a pouch. Bilateral ureters were implanted by inserting 1 cm distal segment into the pouch. The bottom of pouch was opened and anastomosed with the urethra. Results Forty-two patients were followed up for 6 to 96 months,90.5% of whom were continent in the daytime, and 85.7% at night. Two patients had a difficulty in urination. The average volume of the pouch was (361±48) ml at 12 months postoperation. Urodynamic examination showed the average peak voiding pressure was (86.8±21.4) cmH 2O. The average maximum flow rate (Qmax) was (18.4±6.1) ml/s. No remarkable ureter reflux and obstruction were found. No patient was detected to have urethral carcinoma.Conclusions Extraperitoneal cystectomy can avoid the tumor contamination of the abdomen and intestinal interference of the operative field. The ureter-inserting implantation technique is a simple anti-reflux anastomosis method with less ureter stenosis rate. Isolating the neobladder and ureters from the peritoneal cavity can reduce the postoperative complications, such as adhesive ileus, internal hernia, and urine leakage into the peritoneal cavity. The neobladder is similar to the original bladder in position, volume, shape and anti-reflux ureter connection.