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.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer(Part 1).Review and detailed characterization of ileal conduit and modified Indiana pouch

Objective:To review the most used robot-assisted cutaneous urinary diversion(CUD)after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives,including new consistent images Methods:A non-systematic review of the literature with the keywords“bladder cancer”,“cutaneous urinary diversion”,and“radical cystectomy”was performed.Results:Twenty-four studies of intracorporeal ileal conduit(ICIC)and two of intracorporeal Indiana pouch(ICIP)were included in the analysis.Regarding ICIC,the patients’age ranged from 60 to 76 years.The operative time to perform a urinary diversion ranged from 60 to 133 min.The total estimated blood loss ranged from 200 to 1117 mL.The rate of positive surgical margins ranged from 0%to 14.3%.Early minor and major complication rates ranged from 0%to 71.4%and from 0%to 53.4%,respectively.Late minor and major complication rates ranged from 0%to 66%and from 0%to 32%,respectively.Totally ICIP data are limited to one case report and one clinical series.Conclusion:The most frequent type of CUD is ICIC.Randomized studies comparing the performance of the different types of CUD,the performance in an intra-or extracorporeal manner,or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature.To this day,there are not enough quality data to determine the supremacy of one technique.This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects,operative and perioperative outcomes,and new consistent images for each technique.

Robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion

Robot-assisted radical cystectomy with intracorporeal urinary diversion(RARCICUD)has only recently been explored as a viable surgical option for patients with muscle-invasive bladder cancer seeking satisfactory oncologic control while benefiting from minimally invasive surgical techniques.Inspired by earlier open and laparoscopic work,initial descriptions of RARC-ICUD were published in 2003,and have since been followed by multiple larger case series which have suggested promising outcomes for our patients.However,the rate of adoption has remained relatively slow when compared to other robotassisted procedures such as the radical prostatectomy,likely owing to longer operative times,operative complexity,costs,and uncertainty regarding oncologic efficacy.The operative technique for RARC-ICUD has evolved over the past decade and several high-volume centers have shared tips to improve efficiency and make the operation possible for a growing number of urologists.Though there are still questions regarding economic costs,effectiveness,and generalizability of outcomes reported in published data,a growing dataset has brought us ever closer to the answers.Here,we present our current operative technique for RARC-ICUD and discuss the state of the literature so that the urologist may hold an informed discussion with his or her patients.

Serum cystatin C can be used as a marker of renal function even in patients with intestinal urinary diversion

Objective:Recently,serum cystatin C(CysC)has been used as a novel marker of renal function.However,there is a lack of data on CysC levels in patients with intestinal urinary diversion(UD).Here we report CysC levels in such patients.Methods:We prospectively observed 38 patients who were diagnosed with bladder cancer and subsequently treated with radical cystectomy and UD at our institution in 2012 and 2013.Serum creatinine(sCr)and CysC were obtained optionally at the same time at least 1 month after radical cystectomy and UD.Results:The median CysC and sCr concentrations were 1.12 mg/L(range 0.75-2.47 mg/L)and 0.99 mg/dL(range 0.61-2.22 mg/dL),respectively.The median estimated concentrations of glomerular filtration rate(GFR)based on CysC(eGFRcys)and GFR based on creatinine(eGFRcreat)were 61.08 mL/min/1.73 m^2(range 22.64e99.89 mL/min/1.73 m^2)and 58.01 mL/min/1.73 m^2(range 23.48e91.82 mL/min/1.73 m2),respectively.CysC had a significant correlation with sCr(r=0.8607,p<0.0001)and eGFRcreat(r=-0.8993,p<0.0001).eGFRcys also had a significant correlation with eGFRcreat(r=0.8104,p<0.0001).Conclusion:The correlation between CysC and sCr was strong and the correlation coefficient was equivalent to that in patients without UD.The results suggest that CysC is not affected by UD and can be used as a marker of renal function similarly to sCr in patients with UD.

Tissue-engineered conduit using bladder acellular matrix and bladder epithelial cells for urinary diversion in rabbits

Background For muscle invasive bladder cancer, radical cystectomy is the most effective treatment now and urinary diversion is often necessary. The use of intestinal tissue for urinary diversion is frequently associated with complications. In this study, we aimed to make a tissue-engineered conduit （TEC） using bladder epithelial cells and bladder acellular matrix （BAM） for urinary diversion in rabbits. Methods Bladder epithelial cells of rabbit were cultivated and expanded in vitro, then seeded on BAM, and cultured for 7 days. Then cell-seeded graft was used to make TEC. In the experimental group, most of bladder of the rabbit was removed while bladder trigone was retained. The proximal end of TEC was anastomosed with bladder trigone and the distal end was anastomosed with the abdominal stoma. In the control group, TEC was made using unseeded BAM. Haematoxylin and eosin staining was conducted, respectively, at 1, 2, 4, and 8 weeks postoperatively. Immunohistochemistry was performed 8 weeks postoperatively. Intravenous urography, retrograde pyelography, and cystoscopy of TEC were made at 12 weeks postoperatively. Results All animals were alive in the experimental group. Haematoxylin and eosin staining showed epithelial coverage in TEC. Immunohistochemistry showed anti-cytokeratin AEI/AE3 antibody and anti-ZO1 antibody positive, confirming there were mature and functional epithelial cells on the lumen of TEC. Retrograde pyelography and intravenous urography showed that TEC developed well and that there was no obstruction. In the control group, four rabbits were dead within 2 weeks and scar formation, atresia, and severe hydronephrosis were found. Conclusions We successfully made TEC using BAM and bladder epithelial cells for urinary diversion in rabbits. The lumen of this new TEC covered mature epithelial cells and could prevent urinary extravasation.

High Urine Retention: Experience in a Series of Patients with Renal Failure Patients

Purpose: High urinary retention (HUR) can negatively impact renal function. Our study aimed to present the epidemiological, diagnostic, and therapeutic aspects of HUR in a Senegalese academic hospital. Patients and Methods: We conducted a retrospective study of 70 patients with HUR associated with renal failure from January 2017 to December 2020. Parameters examined included: age, sex, coexisting conditions affecting renal function, clinical symptoms, diagnostic tests, causes of HUR, urinary diversion, and patient outcomes. Results: The average age was 66, with a majority of male patients (87%). Twenty-three patients had pre-existing medical conditions. Oligo-anuria was the most common reason for detecting HUR (70%). Half of the patients had an ECOG score ≥ 2. The mean creatinine level was 50.7 mg/l. Nineteen patients exhibited hydroelectrolytic disorders. Bacterial colonization was observed in 25 patients. Ultrasound and computed tomography were the most frequently performed imaging tests (100% and 62.8%, respectively). Sixty-seven patients had ureterohydronephrosis (UHN), with bilateral UHN in 88.6% of cases. Pelvic cancers (47.1%) were the primary cause of HUR, primarily bladder cancers (27.1%). Nephrostomy was the most common urinary drainage method (50%), particularly for obstructions due to pelvic cancer (88.6%). The majority of patients (52.8%) regained normal renal function after drainage. Nineteen deaths occurred among elderly patients with compromised general health. Conclusion: Urinary drainage significantly improved renal function for most patients. Pelvic cancer emerged as the leading cause of HUR. Nephrostomy was the predominant drainage method.

Transperitoneal Laparoscopic Cystoprostatectomy for Muscle Invasive Bladder Cancer: Results and Oncologic Outcomes in a Single Center in Douala Cameroon

Background and Aim: Radical cystectomy is the treatment of choice for muscle-invasive bladder cancer. Although open surgery is currently the gold standard for this procedure, it can also be done via laparoscopy. We aimed to evaluate the oncologic results and the place of laparoscopic cystectomy in the management of bladder cancer in a single urology center in Douala, Cameroon. Patients and Methods: This is a prospective, single-center study carried out from 2015 to 2019. We included 12 patients (ten men and two women) with bladder cancer who underwent total radical laparoscopic transperitoneal cystectomy with ilio-obturator lymph node dissection. Data on patients’ demographic characteristics, pre-operative and postoperative clinical parameters and workup results, and surgical outcomes were collected to determine the overall survival using a Kaplan-Meier curve. Results: We recruited ten men and two women with a median age of 61.5 [52.8 - 68.5] years. The mean tumor diameter was 3.75 ± 1.06 cm. Three (25%) patients received adjuvant chemotherapy while eight did not. The mean surgery duration was 242 ± 45.85 minutes. Blood vessels and nerves were preserved in four (33.33%) patients during surgery. Transitional cell carcinoma was found in 10 (83.33%) patients while epidermoid carcinoma was found in two (16.67%) patients. Metastasis occurred in four (33.33%) patients while the tumor recurred in two (16.67%) patients who later died. Bricker’s ileal conduit urinary diversion was performed in 10 (83.33%) patients while the Studer neobladder was used in two (16.67%) patients. The mean duration of hospitalization was 6 ± 1.48 days. Only one patient (8.33%) developed a postoperative complication. Six (50%) of the patients died while six survived. The median overall survival was 486 days and the five-year overall survival rate was 46.47%. Conclusion: Laparoscopic cystectomy is a mini-invasive technique associated with good cancer control. When performed by well-trained staff using specialized equipment, it can be a safe and effective method of managing muscle-invasive bladder cancer.

Modified Ureterosigmoidostomy

Objective To introduce an operation procedure and evaluate the continence diversion results of the modified ureterosigmoidostomy after radical cystectomy. Methods Fourteen cases of bladder cancer or prostate carcinoma were operated on with modified Sigma pouch from Feb, 1998 to Dec, 1999. A longitudinal incision about 25 cm on the sigmoid wall was done to form a low pressure pouch. The vertex of the new pouch was fixed to sacrum. Both ends of ureters were anastomosed side to side and to form a big nipple and inserted into the top of pouch for 2 to 3 centimeters.Results It took about sixty five minutes to create a new low pressure pouch after radical cystectomy. Early complication of was found in two cases postoperatively, and cured with temporary colonostomy. Hydronephrosis and hypokalemia in one patient were cured by percutaneous anterograde ureter dilatation with balloon and oral replacement of potassium salt. All patients displayed urinary continence. No symptomatic renal infection or hypercholoraemic acidosis occurred. Conclusion Modified ureterosigmoidostomy is a safe procedure of urinary diversion and provides a big volume, low intravesical pressure pouch. The patients are free from the troublesome urine bag, intermittert catheterization, and upper urinary tracts are protected effectively. The quality of life is satisfied.

Diagnosis and Treatment of Urinary Incontinence after Orthotopic Ileal Neobladder in China

INTRODUCTIONRadical cystectomy for bladder and urinary diversion is considered the gold standard for treatment of muscular invasive bladder cancer or high-risk nonmuscular invasive bladder cancer. Urinary diversion is usually classified into three types： orthotopic neobladder, ileal conduit or sigmoid conduit, and cutaneous ureterostomy Orthotopic neobladder is a better choice for urinary diversion than the other types because of its nonurinary diversion and better quality of life when this method is feasible for patients. One of the complications after creating an orthotopic neobladder is urinary incontinence. With an increasing amount of orthotopic neobladder procedures, more patients are suffering from urinary incontinence. Therefore, an article is required for diagnosis and treatment of urinary incontinence after the orthotopic ileal neobladder procedure.

Reinforcing the continent mechanism of continent cutaneous diversions by wrapped rectus abdominis muscle flap： a preliminary experimental study

Background Continent cutaneous diversion （CCD） has been widely used in almost any lower urinary reconstruction. We have been continually trying to modify this procedure because of the high complications rate, especially as they relate to the efferent tube. In this study, we reported a modified procedure with a tapered ileum wrapped by the rectus abdominalis flap （RAMF） and assessed the feasibility of this new technique to achieve urinary continence. Methods A procedure in which two ileal segments were tapered and connected to a U-shaped reservoir was performed in ten dogs. A RAMF with its blood supply was wrapped around one of the tapered ileum. In control groups, the tapered ileum was brought to the abdominal skin. Urodynamic studies were conducted In the 1st, 3rd and 6th months post-operatively. The data of maximum inner pressure （MIP） and functional pressure length （FPL） in every group at each phase were recorded. Retrograde radiograms of the efferent limbs were performed before sacrifice. Results MIP in the study group was significantly higher than that in the control group at each phase （P 〈0.05）. However no significant differences in MIP or FPL were found in the study group between an empty and full reservoir. In the control group, MIP increased （P 〈0.05） and FPL decreased significantly （P 〈0.05） compared with an empty and full reservoir. Retrograde radiograms confirmed that efferent limbs were positioned straigh beneath the abdominal wall. Histological examination of the study group demonstrated a layer of striated muscle around the outside surface of the ileum. Conclusion The continent mechanism of tapered ileum can be enhanced by extra support from wrapped RAMF.

An improved ileal conduit surgery for bladder cancer with fewer complications

Background:Radical cystectomy and urinary diversion remains the standard surgical treatment for patients with muscle-invasive or high-risk or recurrent non-muscle-invasive bladder cancer.Although this approach prolongs patient survival remarkably,there are postoperative complications associated with urinary diversion.This study aimed to assess the efficacy of modified ileal conduit surgery for reducing early and late stoma-and ureteroileal anastomo-sis-related complications,as compared with conventional ileal conduit urinary diversion.Methods:We retrospectively evaluated the clinical data of bladder cancer patients treated with radical cystectomy and ileal conduit urinary diversion at Sun Yat-sen University Cancer Center between January 1,2000 and June 30,2016.Ileal conduit was created by the conventional or a modified technique.The clinicopathologic features of the conventional and the modified ileal conduit groups were compared using the t test and the Chi square test.Multivari-able logistic regression analysis and multivariable Cox regression analysis were performed to determine the odds of developing stoma-and ureteroileal anastomosis-related complications in the two groups.Results:145 and 100 patients underwent the modified and conventional ileal conduit surgery,respectively.The two groups were comparable with regard to clinicopathologic features.The rate of stoma-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group(0.7%vs.17.0%,P<0.001).No late stoma-related complications were seen in the modified ileal conduit group,but were seen in 13(13.0%)patients in the conventional ileal conduit group.The rate of ureteroileal anastomosis-related complications was significantly lower in the modified ileal conduit group than in the conventional ileal conduit group(4.8%vs.15.0%,P=0.001).In multivariable analyses,the modified ileal conduit group was significantly less likely to develop stoma-(odds ratio[OR]=0.024,95%confidence interval[CI]0.003-0.235;P=0.001)or ureteroileal anastomosis-related complications(OR=0.141,95%CI 0.042-0.476;P=0.002)than the conventional ileal conduit group.Conclusions:Our modified surgical technique for ileal conduit urinary diversion may be effective for reducing early and late complications related to the stoma and the ureteroileal anastomosis.Prospective randomized clinical trials are needed to confirm our results.

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.