Campbell-Walsh Urology, 11th Edition

PART XIII

Benign and Malignant Bladder Disorders

99

Orthotopic Urinary Diversion

Eila C. Skinner; Siamak Daneshmand

Questions

  1. Which of the following was the key finding that allowed application of orthotopic urinary diversion to women undergoing cystectomy?
  2. Confirmation that an intact bladder neck is required for continence
  3. Demonstration in cystectomy specimens that urethral involvement was rare in the absence of tumor at the bladder neck
  4. Understanding of the relationship between estrogen levels and continence in elderly women
  5. Studies showing that direct invasion into the uterus is relatively rare in women with invasive bladder cancer
  6. Quality-of-life studies showing that men with continent diversion had better quality of life than those with ileal conduit
  7. The risk factor most predictive for urethra recurrence following cystectomy for urothelial carcinoma is:
  8. prostatic stromal invasion.
  9. node-positive disease.
  10. carcinoma in situ (CIS) in females.
  11. pathologic stage pT3b tumor at the trigone.
  12. history of multiple prior tumors.
  13. An 80-year-old man with clinical cT2 bladder cancer lives alone but is active. His serum creatinine is 1.0 following neoadjuvant gemcitabine and cisplatin chemotherapy. He is interested in an orthotopic diversion. If he elects to have a continent diversion, the most important information to provide him so that postoperative expectations are met is:
  14. neoadjuvant chemotherapy increases the early complications of orthotopic diversion.
  15. older patients take longer to regain continence than younger patients.
  16. ileal conduit will be easier for him to take care of than a continent diversion.
  17. pyelonephritis is more common with continent diversion than ileal conduit.
  18. his risk of renal deterioration with continent diversion is higher than with ileal conduit.
  19. Which of the following patients should NOT be offered an orthotopic neobladder?
  20. An 82-year-old healthy woman with recurrent cT1 and CIS following intravesical bacille Calmette-Guérin (BCG) and a prior vaginal hysterectomy
  21. A 53-year-old woman with an estimated glomerular filtration rate (eGFR) of 55 following neoadjuvant chemotherapy
  22. A 50-year-old man 2 years following low anterior colon resection with adjuvant chemotherapy and external beam radiation to the pelvis
  23. A 60-year-old woman with diabetes and hypertension
  24. A 58-year-old woman with palpable induration of the anterior vaginal apex
  25. Which of these is a key requirement for construction of an orthotopic diversion?
  26. It should prevent vesicoureteral reflux to preserve renal function.
  27. It should be made of ileum or a combination of colon and ileum.
  28. The bowel used should be detubularized and fashioned into a spherical shape.
  29. It should be made with the smallest amount of bowel possible.
  30. The ureters should be anastomosed to an isoperistaltic segment of bowel.
  31. Which of the following have been suggested to decrease the risk of urinary retention following ileal neobladder in women?
  32. Regular urethral dilation
  33. Tack the pouch to the anterior abdominal wall
  34. Biofeedback training in the early postoperative period
  35. Preservation of the uterus
  36. Construct a Wpouch rather than a Studer type pouch
  37. In performing a cystectomy and orthotopic ileal neobladder in a male, the most important step in preserving continence is to:
  38. construct a large-capacity reservoir.
  39. avoid excess dissection anterior to the urethra.
  40. perform a nerve-sparing procedure in all cases.
  41. avoid removal of the presacral lymph nodes.
  42. place a suprapubic catheter during the early postoperative period.
  43. A 64-year-old man with recurrent CIS who strongly prefers an orthotopic or continent cutaneous diversion is found to have grossly node-positive disease at surgery. The next step is:
  44. close and refer for chemotherapy and radiation.
  45. complete the cystectomy but do an ileal conduit.
  46. complete the cystectomy but do a continent cutaneous diversion.
  47. complete the cystectomy and neobladder and refer for adjuvant chemotherapy.
  48. complete the cystectomy and neobladder and refer for adjuvant radiation therapy.
  49. Before considering a continent orthotopic diversion, what evaluation is mandatory?
  50. Prostatic urethral biopsy
  51. Evaluation of renal function
  52. Colonoscopy to rule out colon polyps
  53. Biopsy of the bladder neck in a female
  54. Video-urodynamics to test the integrity of the external sphincter
  55. The primary innervation of the rhabdosphincter that is responsible for continence in men and women following an orthotopic diversion is:
  56. parasympathetics from S2-S4.
  57. anterior branches of the sciatic nerve.
  58. sympathetic nerves from the hypogastric plexus.
  59. pudendal nerve.
  60. femoral nerve.
  61. Use of metallic surgical staples should be avoided in construction of a continent diversion because:
  62. it is less secure than a hand-sewn closure.
  63. they tend to be buried in the bowel mucosa.
  64. the staples increases the risk of subsequent infection.
  65. the staples become a nidus for stone formation.
  66. they increase the risk of cancer developing in the segment.
  67. A 71-year-old male is found on routine follow-up to have a pelvic recurrence 13 months after cystectomy and ileal neobladder. The mass is 2.5 cm in the obturator fossa, abutting the pouch. There is no hydronephrosis. He has good daytime continence but occasionally leaks at night. The next step is:
  68. resection of the mass with removal of the pouch and conversion to an ileal conduit.
  69. cystoscopy to look for invasion of the reservoir.
  70. placement of a permanent suprapubic tube.
  71. resection of the mass with preservation of the neobladder.
  72. systemic chemotherapy with or without external beam radiation.
  73. Asymptomatic bacteriuria in patients with orthotopic diversion:
  74. carries a high risk of subsequent pyelonephritis.
  75. leads to an increase in urethral recurrence.
  76. does not generally require treatment.
  77. is very rare in most reported series.
  78. suggests probable outlet obstruction.
  79. A 59-year-old man is 6 years out from a radical cystectomy and neobladder. He had excellent day and nighttime continence and no problems with infections, but recently has started to leak at night. The next step is:
  80. video-urodynamics.
  81. computed tomography (CT) scan looking for local recurrence.
  82. check postvoid residual.
  83. trial of long-term antibiotics.
  84. magnetic resonance imaging (MRI) of the spine.
  85. A 66-year-old male 2 years after a cystectomy and Hautmann ileal neobladder for pathologic stage T2N0M0 bladder cancer is found on routine CT scan to have a very distended neobladder and mild bilateral hydronephrosis. He has a postvoid residual of over 800 mL. Cystoscopy and digital rectal exam are normal. The next step is:
  86. teach the patient intermittent catheterization.
  87. dilate the urethra with van Buren sounds.
  88. instruct the patient to credé while Valsava voiding.
  89. convert the diversion to an ileal conduit.
  90. decompress the neobladder with a catheter for 2 weeks and then resume regular voiding.
  91. Quality-of-life studies of patients with orthotopic diversion:
  92. are best done by the physician asking the patient about the function of his/her neobladder.
  93. have generally shown that patients with continent diversions have a better quality of life than those with ileal conduits.
  94. can be easily done with currently available questionnaires used for other populations.
  95. have often been underpowered or affected by selection bias.
  96. have shown that most patients with any urinary diversion have very poor quality of life.
  97. A 70-year-old man who is 10 days postcystectomy and neobladder is readmitted with fever, and CT scan shows a large fluid collection near the reservoir that fills with contrast on delayed images. The catheter and ureteral stents are still in place. The next step is:
  98. intravenous (IV) antibiotics and observation with frequent catheter irrigation.
  99. exploration and repair of the pouch.
  100. bilateral percutaneous nephrostomy tube placement.
  101. percutaneous drainage of the fluid collection.
  102. percutaneous placement of a suprapubic catheter.
  103. A 53-year-old woman had an anterior exenteration and neobladder with omental flap interposition 3 months previously. She still has total incontinence day and night. The next step is:
  104. reassurance and reinforce Kegel exercises.
  105. refer for physical therapy for pelvic floor strengthening.
  106. evaluate for possible vesicovaginal fistula.
  107. prescribe extended-release oxybutynin.
  108. fluorourodynamics.
  109. A 70-year-old woman had a cystectomy and ileal neobladder diversion 5 years ago for pT2N0 urothelial cancer. CT scan is normal, and she has excellent continence and empties well with negative urine culture. The next step is:
  110. refer her to her primary care physician for routine health maintenance.
  111. continue annual CT abdomen and pelvis out to 10 years.
  112. annual endoscopy of the pouch to screen for secondary malignancy.
  113. annual cystogram and serum creatinine to evaluate for reflux nephropathy.
  114. renal ultrasound and vitamin B12level every 1 to 2 years.
  115. Which of the following is NOT usually part of an Early Recovery After Surgery (ERAS) protocol applied to patients undergoing radical cystectomy?
  116. Alvimopan BID beginning on the morning of surgery
  117. Early feeding
  118. No mechanical or antibiotic bowel prep
  119. Continuous IV narcotics to optimize pain management
  120. Early removal of nasogastric tubes
  121. An otherwise healthy 90-year-old man had a cystectomy and ileal neobladder 15 years previously with a hemi-Kock pouch to the urethra. He presented with a creatinine of 4.0 and bilateral hydronephrosis on renal ultrasound that did not resolve with catheter drainage. The most likely cause of his problem is:
  122. bilateral ureteral stones.
  123. stenosis of the afferent nipple valve.
  124. reflux nephropathy.
  125. urinary retention.
  126. cancer recurrence in the reservoir.
  127. Which of the following is TRUE about robotic cystectomy with extracorporeal neobladder construction compared with standard open cystectomy?
  128. Patients undergoing robot-assisted radical cystectomy have significantly fewer early and late complications.
  129. Continence has been shown to be improved.
  130. Long-term cancer control has been proven to be equivalent.
  131. The surgery can be performed through a smaller incision.
  132. Hospital stay has been shorter in the minimally invasive surgical series.
  133. A 66-year-old man had a cystectomy and sigmoid neobladder 4 years previously and has good continence. He was noted on recent CT scan to have two 0.7-cm calcifications in the pouch. The next step is:
  134. reassurance that the stones will probably pass.
  135. shockwave lithotripsy.
  136. metabolic stone evaluation.
  137. begin intermittent catheterization.
  138. cystoscopy and extraction of the stone.
  139. A 49-year-old man had a cystectomy and neobladder 4 months previously. He has excellent continence in the daytime but still has accidents at night even though he gets up twice to empty. The next step is:
  140. reassurance that the nighttime continence will likely improve with more time.
  141. trial of extended release oxybutynin.
  142. strict fluid restriction to no more than 1500 mL per day.
  143. intermittent catheterization.
  144. refer for physical therapy for pelvic floor strengthening.

Answers

  1. b. Demonstration in cystectomy specimens that urethral involvement was rare in the absence of tumor at the bladder neck.The two findings that paved the way for orthotopic diversion in women were retrospective pathologic studies showing that urethral involvement was rare in the absence of bladder neck involvement (in other words, “skip lesions” were rarely seen, suggesting oncologic safety) and studies showing that women could be continent without an intact bladder neck (previously thought to be required).
  2. a. Prostatic stromal invasion.Two large studies have demonstrated conclusively that urethral recurrence in men is associated with prostatic stromal invasion in the cystectomy specimen.
  3. b. Older patients take longer to regain continence than younger patients.Older men regain continence more slowly than younger men, but the majority of fit older men will ultimately have good control, especially in the daytime. Older men often have difficulty becoming independent in managing an ileal conduit, and in a man living alone a neobladder may actually be simpler.
  4. e. A 58-year-old woman with palpable induration of the anterior vaginal apex. Women with palpable invasion of the anterior vaginal wall have a high risk of urethral tumor and should not undergo orthotopic diversion.
  5. c. The bowel used should be detubularized and fashioned into a spherical shape.Orthotopic diversions can be made from small or large bowel. The key to obtaining a low-pressure reservoir with good volume is to detubularize the segment and reconfigure it into a spherical shape.
  6. d. Preservation of the uterus. Late urinary retention ("hypercontinence") in women appears to be primarily due to posterior displacement of the pouch into the vagina resulting in a kinking at the urethral anastomosis.A number of maneuvers have been suggested such as sacroculpopexy, but preservation of the uterus appears to be the most promising.
  7. b. Avoid excess dissection anterior to the urethra. In preserving the urethra for an orthotopic bladder in males, one should be careful of the dorsal venous complex and avoid deep bites into the pelvic floor, especially anterior to the urethra where the rhabdosphincter is the most developed.
  8. d. Complete the cystectomy and neobladder and refer for adjuvant chemotherapy.Patients with node-positive disease have a poor prognosis, but up to 30% may be long-term survivors, especially with adjuvant chemotherapy. Orthotopic diversion should not impact survival, and if a patient is highly motivated to avoid a stoma, this option can still be pursued.
  9. b. Evaluation of renal function.In order to be considered a candidate for a continent diversion, a patient must have a glomerular filtration rate (GFR) in excess of 35 mL/min, and the kidneys must be capable of concentrating and acidifying the urine.
  10. d. Pudendal nerve.The rhabdosphincter is innervated by the pudendal somatic nerve. The contribution to continence from the pelvic autonomic plexus is uncertain, although some nonrandomized studies suggest that preserving the neurovascular bundle posterolateral to the prostate may improve continence.
  11. d. The staples become a nidus for stone formation.Metallic staples have a high association with subsequent stone formation, as was seen in the long-term experience with the hemi-Kock pouch. Recent efforts to perform intracorporeal neobladder using minimally invasive techniques have advocated using GIA staplers, but early results have suggested a high risk of stones.
  12. e. Systemic chemotherapy with or without external beam radiation. Local recurrence of urothelial cancer will not usually impact the neobladder function.Rarely, direct invasion of the reservoir will cause bleeding or outlet obstruction. Prognosis is poor, and local resection is rarely successful in eradicating the tumor, so primary treatment should be systemic chemotherapy and possibly radiation (which can be safely applied around a neobladder).
  13. c. Does not generally require treatment. In patients with orthotopic bladders, approximately one quarter have asymptomatic bacteriuria.After the initial 6 months it is rare for patients to have symptomatic infections or pyelonephritis, and bacteriuria does not require treatment.
  14. c. Check postvoid residual.Patients who have a change in their continence after initial good function should be evaluated for possible urinary retention. This is often the first sign of incomplete emptying. Urodynamics are not necessary unless the pouch is made from colon, because ileal neobladders are very reliably low-pressure with good compliance.
  15. a. Teach the patient intermittent catheterization. All patients who are considered for a continent diversion should be willing and able to perform self-catheterization.The likelihood of needing self-catheterization is lower in men than in women, with reported rates of 10% to 40% in most series.
  16. d. Have often been underpowered or affected by selection bias. Quality-of-life surveys have not shown one type of urinary diversion to be superior over another, though the vast majority of studies have serious methodological flaws.Obviously, randomized studies in this area have been impossible. Most patients are reasonably well adapted socially, physically, and psychologically to their diversion. The key to this adaptation is appropriate and realistic preoperative education.
  17. d. Percutaneous drainage of the fluid collection. If a patient has an undrained urine leak postoperatively, percutaneous drainage is the first step.Nephrostomy tubes can be placed if a large urine leak does not respond to percutaneous drainage with optimal catheter drainage. Open surgical repair should be avoided if possible because the complication rate is high and success in closing the leak in the face of acute postsurgical inflammation is low.
  18. c. Evaluate for possible vesicovaginal fistula. A woman with persistent incontinence should be evaluated for a pouch vaginal fistula. This is most common when the anterior vaginal wall is removed with the specimen. It is best prevented by interposition of an omental pedicle but still can occur.Evaluation is easily performed with a speculum exam with methylene blue in the bladder.
  19. e. Renal ultrasound and vitamin B12level every 1 to 2 years. Long-term risks in diversion patients include late ureteral stricture, stones, decreased bone density, and vitamin B12 deficiency. All of these can be silent, so long-term routine follow-up is required. Most primary care physicians are not familiar with this.
  20. d. Continuous IV narcotics to optimize pain management.New ERAS protocols have resulted in shorter hospital stay. Avoidance of bowel prep and the use of the μ opioid inhibitor alvimopan have been proven effective in randomized trials.
  21. b. Stenosis of the afferent nipple valve. Afferent nipple stenosis is a well-documented late complication of the classic hemi-Kock pouch with an intussuscepted nipple valve antireflux mechanism.Treatment includes nephrostomy tube placement and endoscopic incision of the valve mechanism.
  22. d. The surgery can be performed through a smaller incision.A large series of patients undergoing robotic-assisted cystectomy with extracorporeal diversion showed no decrease in hospital stay or early or late complications compared with open series, and this was confirmed in one recent randomized trial from Memorial Sloan-Kettering. Oncologic efficacy appears to be similar, but long-term results are not yet available.
  23. e. Cystoscopy and extraction of the stone.Stones can occur in all types of continent diversions. These stones should be removed endoscopically while they are still small.
  24. a. Reassurance that the nighttime continence will likely improve with more time. Patients typically attain nighttime continence more slowly than daytime, with patients reporting improvement out to 1 to 2 years.Early on there is an obligate nocturnal diuresis from the pouch that aggravates this. If the patient has good daytime control, further efforts to strengthen the sphincter are unlikely to help the nighttime continence. There is no role for anticholinergics or urodynamics in this setting.

Chapter review

  1. The volume of the reservoir generally increases over time. Reservoirs constructed from ileum generally have a greater increase in volume over time than pouches constructed with colon.
  2. The risk factors in women that are most predictive of urethral cancer developing are vaginal wall invasion or bladder neck involvement of transitional cell carcinoma.
  3. The majority of patients who have a urethral recurrence are symptomatic on presentation. A urinary cytology has a variable rate of yield but is generally low in this group of patients.
  4. When orthotopic bladders are constructed in elderly patients, there is a slower time to achieve continence, an increased rate of stress incontinence, and an increased incidence of nighttime incontinence when compared with younger patients.
  5. In order to consider a patient a candidate for a continent diversion, he or she must have a glomerular filtration rate (GFR) in excess of 60 mL/min, and the kidneys must be capable of concentrating and acidifying the urine. A minimum GFR of 35 mL/min is required for a conduit diversion if metabolic problems are to be manageable.
  6. All patients who are considered for a continent diversion should be willing and able to perform self-catheterization, although for selected patients this may not be necessary.
  7. In preserving the urethra for an orthotopic bladder in males, one should be careful of the dorsal venous complex, preserve the puboprostatic ligaments, and avoid deep bites into the pelvic floor. In females, the endopelvic fascia and levator muscles should be preserved.
  8. In patients with orthotopic bladders, approximately one quarter have asymptomatic bacteriuria.
  9. The need to perform an antireflux mechanism for the ureters in an orthotopic urinary diversion is unproved.
  10. If there is any suggestion that a nerve-sparing technique might result in a positive surgical margin, the nerve should be sacrificed. This does not mean that the diversion cannot be successfully performed or that the patient will not be continent.
  11. Nighttime incontinence occurs in approximately 25% to 75% of patients.
  12. Urinary retention following orthotopic urinary diversion occurs in 10% to 25% of patients and is more common in women than in men.
  13. It may take 3 to 6 months for daytime continence to develop in many patients. Nocturnal continence may take more than a year after surgery.
  14. If a patient has an undrained urine leak postoperatively, percutaneous drainage and/or nephrostomy is preferable to open surgical repair because the latter is extremely difficult and the complication rate is high.
  15. Obstruction from an antireflux valve may be clinically silent, and patients may present with hydronephrosis and/or renal failure.
  16. A pouch vaginal fistula is a morbid complication in female patients and is most likely to occur when the anterior vagina is removed along with the bladder. It is best prevented by interposition of an omental pedicle.
  17. Quality-of-life surveys have not shown one type of urinary diversion to be superior over another. Most patients are reasonably well adapted socially, physically, and psychologically to their diversion. The key to this adaptation is appropriate and realistic preoperative education.
  18. Preserving the uterus and vagina and their supporting structures limits the risk of a vaginal fistula, improves sexual function, and may decrease urinary retention in women who undergo a continent diversion.
  19. The absence of the guarding reflex and increased volume output at night due to secretion of fluid by the bowel and the physiologic diuresis that occurs in older patients in the supine position contributes to nighttime incontinence.
  20. In women, one fourth will have daytime leakage, one third will have nighttime leakage, and two thirds will require self-catheterization at least once a day.
  21. Women with palpable invasion of the anterior vaginal wall have a high risk of urethral tumor and should not undergo orthotopic diversion.
  22. Long-term risks in diversion patients include late ureteral stricture, stones, decreased bone density, and vitamin B12deficiency.

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