Yoichi Arai, Atsushi Takeda, Masanori Kato; Tohoku University Graduate School of Medicine, Sendai. Yoji Taki, Hideo Takeuchi; Toyooka Public Hospital, Toyooka. Akito Tearai; Kurashiki Central Hospital, Kurashiki. Tatushiro Okabe; Shiga Medical Center for Adult Diseases, Moriyama. Teruo Konami; Otsu Municipal Hospital, Otsu. Mieko Miyakawa; Shimada Municipal Hospital, Shimada. Mutsushi Kawakita; Kobe City General Hospital, Kobe. Asaki Soeda; Nishi-Kobe Medical Center, Kobe. Yoshihiko Wakabayashi, Yusaku Okada; Shiga University of Medical Science, Otsu. Arata Higashi, Osamu Ogawa; Kyoto University Hospital, Kyoto.
5-year interval change in voiding function of orthotopic ileal neobladder
Version of Record online: 6 JUL 2006
International Journal of Urology
Volume 13, Issue 6, pages 703–706, June 2006
How to Cite
ARAI, Y., TAKEDA, A., TAKI, Y., OKADA, Y., OGAWA, O. and THE TOHOKU-KYOTO URINARY RECONSTRUCTION STUDY GROUP (2006), 5-year interval change in voiding function of orthotopic ileal neobladder. International Journal of Urology, 13: 703–706. doi: 10.1111/j.1442-2042.2006.01389.x
- Issue online: 6 JUL 2006
- Version of Record online: 6 JUL 2006
- Received 5 September 2005; accepted 15 November 2005.
- urinary reconstruction;
- voiding function
Aim: We report the 5-year interval change in voiding function of orthotopic ileal neobladder.
Methods: Voiding function was evaluated at two points with an interval of 5 years in 49 patients with orthotopic ileal neobladder. The first and second surveys were performed in May, 1998 (1998 survey) and in April 2003 (2003 survey), respectively. Median age at operation was 67 years, ranging 47–77. Median follow-up times at the first and the second surveys were 19.5 months (range, 3–87) and 67.5 months (range, 62–145), respectively.
Results: There was no significant change in daytime continence status between the 1998 and 2003 surveys. More than 95% never or only occasionally suffered daytime incontinence in the two surveys. On the other hand, 15 (34.1%) and 14 (31.8%), respectively, experienced night-time incontinence, despite regular voiding during the night. When voiding patterns were analysed, 11 patients (23.4%) sometimes or often performed catheterization because of difficulty in urinating or incomplete emptying of the neobladder in the 1998 survey. Three patients (6.4%) were unable to void and required regular catheterization. In the 2003 survey, however, such poor voiders increased to nine (19.1%), although the difference was not significant. During the study period of 5 years, there was no change in renal function.
Conclusions: Continence status, either at daytime or at nighttime, was stable during the study period. The number of the patients who needed regular catheterization tended to increase, suggesting deterioration of voiding function with time. Careful long-term follow up is warranted.
The orthotopic neobladder enables patients to void through his or her own urethra. Thus, the neobladder is potentially capable of providing better quality of life for cystectomy patients. To date, many forms of bladder substitute have been reported, all giving comparable results.1–5 There have been only a few reports on longitudinal functional outcome of neobladder creation.6–9 We previously reported voiding function of ileal neobladder in both men and women.6,7 The survey was performed in 1998. In 2003, 5 years after the initial survey, the second survey was performed for the same patients. We herein present the 5-year interval change in voiding function of orthotopic ileal neobladder.
Materials and methods
From November 1990 through February 1998, 71 patients underwent Hautmann bladder substitution in Kyoto University Hospital, Shiga University of Medical Science, and their affiliated hospitals. Among them, voiding function was evaluated at two points with an interval of 5 years in 49 patients, who comprised the study population. There were 43 men and six women, and median age at operation was 67 years old, ranging 47–77. Of these patients, 46 underwent simultaneous radical cystectomy. The three remaining patients underwent simultaneous unilateral nephroureterectomy and cystectomy for primary invasive ureteral cancer in the ureterovesical junction. All patients gave their full consent and were informed about other options for urinary reconstruction. Patients were monitored at regular intervals of 3–6 months. Serum electrolytes, blood urea nitrogen and creatinine measurements, were performed at 3 months and then annually. Uroflowmetric study and postvoid residual urine measurements were performed arbitrarily.
The first and second surveys were performed in May, 1998 (1998 survey) and in April 2003 (2003 survey), respectively. Therefore, at the second survey, follow-up time was at least 5 years or longer. Median follow-up times at the first and the second surveys were 19.5 months (range, 3–87) and 67.5 months (range, 62–145), respectively. We questioned the patients regarding voiding behavior and continence, need for self-catheterization, voiding posture, incontinence, and the need for a pad to manage incontinence. If a patient wore a sanitary pad only for precautionary reasons or had only occasional spotting, he was regarded as continent. Statistical analyses were made using Wilcoxon or χ2-test and P < 0.05 was considered statistically significant.
The data on voiding function in the 1998 and 2003 surveys are shown in the Table 1. Since the study was retrospective, data were not available in some patients in each parameter. When voiding patterns were analysed, 11 patients (23.4%) sometimes or often performed catheterization because of difficulty in urinating or incomplete emptying of the neobladder in the 1998 survey. Three patients (6.4%) were unable to void and required regular catheterization. In the 2003 survey, however, nine (19.1%) were unable to void and needed regular catheterization, although the difference was not significant (P = 0.174). Of these nine patients, eight were male and one was female, thus there was no difference in the need for regular catheterization between the male and female: 18.6% and 16.7%, respectively. With regard to posture at voiding, 23 (52.3%) voided in a regular standing position in the 1998 survey. Eighteen patients (40.9%) preferred a sitting position while voiding, of whom 13 (29.5%) only voided in a sitting position. At the 2003 survey, the rate of regular standing voiders decreased to 43.2%. There was no significant change in daytime continence status between the two surveys. More than 95% never or only occasionally suffered daytime incontinence in the two surveys. Similarly, there was no significant change in daytime pad use between the two surveys: 37 (90.2%) and 36 (87.8%) never required a pad for daytime incontinence at the 1998 and 2003 surveys, respectively. On the other hand, 15 (34.1%) and 14 (31.8%), respectively, experienced night-time incontinence, despite regular voiding during the night. The majority of the patients got up to void once or more per night, even in the 2003 survey. Although there was no significant difference, the rate of night-time pad use decreased from 47.5% to 40%.
|1998 survey||2003 survey||P-value|
|Number of patients||(%)||Number of patients||(%)|
|Difficulty on urination†||0.174|
|Inability to void||3||(6.5)||9||(19.6)|
|Need for catheterization†||0.301|
|Posture at voiding†||0.277|
|Standing position only||23||(52.3)||19||(43.2)|
|Sitting position only||13||(29.5)||10||(22.7)|
|Sitting position, sometimes||5||(11.4)||6||(13.6)|
|Inability to void||3||(6.8)||9||(20.5)|
|None, if voided at night||13||(29.5)||12||(27.3)|
|Yes, despite regular voiding at night||14||(31.8)||13||(29.5)|
|Voiding frequency during night-time†||0.956|
|3 or more||4||(11.1)||5||(13.9)|
|Use of pads during daytime†||0.724|
|Use of pads during night-time†||0.499|
There was no significant change in serum creatinine level between the 1998 and 2003 surveys: 0.80 ± 0.26 (standard deviation) and 0.90 ± 0.29 mg/dL, respectively.
The present study is unique in that functional outcome was assessed at two points with an interval of 5 years. Thus longitudinal change of voiding function was evaluated for the same patients. Overall, continence status, either at daytime or at nighttime, was stable during the study period. More than 90% of the patients had never or occasionally daytime incontinence and about one-third claimed night-time incontinence, despite regular voiding during the night. On the other hand, the number of the patients who needed regular catheterization tended to increase, suggesting deterioration of voiding function with time. Interestingly, more than one-third preferred to void at sitting position. During the study period of 5 years, there was no change in renal function.
Daytime continence was excellent, with more than 90% of the patients remaining dry, or reporting only occasional spotting. This percentage is at least equal to that of a recent meta-analysis of several types of orthotopic bladder substitutions.2,8–12 On the other hand, Hautmann10 indicated that daytime continence rates decrease gradually 4–5 years after neobladder reconstruction. A factor may be declining external urethral sphincter function with age.10 Thus further observation is required.
The probable most bothersome outcome of orthotopic neobladder reconstruction is nocturnal incontinence, which is feature shared by all forms of neobladders. The reported incidence of nocturnal incontinence ranged 0–67%, with an average of 28%.9,10 In our series, about 30% of the patients experienced night-time incontinence despite regular voiding at night and more than 40% used pads during night-time. To diminish the risk of nocturnal incontinence, the majority of our patients got up to void once or more per night. It has been suggested that sleep results in an uncompensated decreased outlet resistance secondary to lack of a reflex arc that would normally signal a full bladder.2 Increased diuresis and shift of free water into the concentrated urine may be another factors explaining night-time incontinence.10
It should be noted that the number of the patients who needed intermittent catheterization tended to increase with time in our series. The number of patients with routine catheterization increased from 3 (6.4%) to 9 (19.1%). At the 2003 survey, about 35% required some form of catheterization to empty the neobladder completely. Our previous study on female neobladder patients also showed deterioration of voiding function with time.7 However, this trend was similar both in male and female patients in the present study. Using the cohort of 209 neobladder patients with median follow up of 33 months, Stein et al.13 also reported that 25% required some form of intermittent catheterization. On the other hand, Studer’s group reported that permanent failure to empty the bladder was not a major problem and only 3% required catheterization after 5 years.8 There has been wide variation in the reported rate of self-catheterization, ranging from 0 to 53%,10 but precise pathogenesis of urinary retention or elevated postvoid residual urine requiring clean intermittent catheterization remains uncertain. Interestingly, 30–40% of the patients preferred a sitting position when voiding. To our knowledge, there have been little reports referring to voiding posture in neobladder patients. Furukawa et al.14 assessed the quality of life of 37 patients, including two women, with an orthotopic ileal neobladder, and found that 58% of the cases voided in a sitting position. As reported by Mikuma et al.,15 neobladder patients void by abdominal straining and relaxation of the pelvic floor musculature. It is speculated that, for some patients, a sitting position helps more efficiently to increase abdominal pressure and relax the pelvic floor musculature than a regular standing position.16
There was no significant change in renal function measured by serum creatinine during the 5-year study period, a finding very similar to that from other studies.10,13 On the other hand, Madersbacher et al.17 recently reported long-term outcome of ileal conduit diversion. The rate of renal functional/morphological alterations increased to 50% of those surviving longer than 15 years. They emphasize the need for more long-term studies more than a decade to determine the entire morbidity spectrum. Thus vigorous long-term follow up is warranted.
We recognize the existence of methodological limitations in the evaluation of voiding function. The study is retrospective and multi-institutional. Further, the evaluation of voiding patterns can be influenced by a physician’s personal interpretation as to the quality of the results. With regard to continence, in particular, one person’s threshold for leakage may be entirely different from another’s, given the same circumstances. Therefore, efforts to evaluate continence should focus on the individual degree of satisfaction with the level of continence, rather than the absolute amount of urinary leakage. In this regard, patient-reported quality of life assessment may be more appropriate for the evaluation of voiding function in patients with an orthotopic neobladder.
We assessed the functional outcome of orthotopic ileal neobladder at two points with an interval of 5 years. Continence status, either at daytime or at nighttime, was stable during the study period. The number of the patients who needed regular catheterization tended to increase, suggesting deterioration of voiding function with time. We plan to follow those currently included in our series to the 10-year mark.