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Objectives: To evaluate the long-term functional outcomes of various types of orthotopic neobladder (NB).
Methods: Eighty-nine patients who underwent orthotopic NB reconstruction after radical cystectomy and were followed for at least 60 months after surgery were included in this retrospective study. The types of NB in this series were: modified Studer type, Hautmann type, Mainz type, Goldwasser type and modified Reddy type in 36, 9, 15, 10 and 19 patients, respectively.
Results: Sixty-seven (75.3%) patients could void spontaneously, 15 (16.8%) voided with clean intermittent catheterization (CIC) assistance and seven (7.9%) with CIC alone. After excluding the seven voiding with CIC alone, daytime and night-time continence was achieved in 63 and 50 of the remaining 82 patients, respectively. In addition, the proportion of daytime continence in the modified Studer group was significantly greater than that in the Mainz group, whereas there was no significant difference in the proportion of night-time continence among these groups. Uroflow examination indicated that despite the lack of significant differences in the maximal flow rates and the voided volumes, the post-void residual in the modified Reddy group was significantly smaller than that in the modified Studer group. Blood gas analysis in the 82 patients showed that there were no significant differences in the pH, bicarbonate, chloride and base excess among these groups.
Conclusions: Orthotopic NB created with intestinal segments generally has acceptable functional outcomes on long term follow up. These outcomes differ according to the type of NB. To define the optimal procedure for NB reconstruction, it is necessary to understand the long-term functional prospects, on which the subjective success of NB creation is based.
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The orthotopic neobladder (NB) has become a common method for reconstruction of the urinary tract following removal of the bladder, since the morbidity of this procedure has decreased with refinements in surgical techniques and the quality of life in patients with NB is generally favorable.1,2 To date, various different methods of NB reconstruction have been developed to achieve the ultimate goal of orthotopic NB with functions similar to that in a normal urinary bladder.1,2 However, several serious problems have been observed after NB creation, among which voiding dysfunction is probably the most important issue adversely affecting the patient's postoperative satisfaction.3
Voiding dysfunction following NB creation can be characterized by the failure to empty the NB and to store urine in the NB, and has been reported to depend on the type of surgical procedure.3–5 For example, Kato et al. reported that the rate of spontaneous voiders in the sigmoid NB group was better than that in the ileal NB group, whereas the ileal NB tends to provide better continence than the sigmoid NB.4 However, the differences in long-term functional outcomes of orthotopic NB according to the types of reconstruction have not been well documented. At our institutions, since 1983, several types of NB replacement such as modified Studer, Hautmann, Mainz, Goldwasser and modified Reddy types, have been carried out after radical cystectomy.6–9 In the present study, the functional outcomes of 89 patients, who underwent NB reconstruction and were followed for at least 5 years, were retrospectively analyzed to characterize long-term voiding dysfunction according to several types of orthotopic NB.
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At our institutions, 406 patients underwent radical cystectomy for bladder cancer and reconstruction of an orthotopic intestinal NB between 1983 and 2006. The types of NB creation used for these patients were as follows: ileal NB in 288 (modified Studer type in 238 and Hautmann type in 50),6 ileocolic NB in 23 (Mainz type),7 ascending colonic NB in 32 (Goldwasser type)8 and sigmoid NB in 63 (modified Reddy type).9 Of these, a total of 89 patients (78 male, 11 female; mean age, 62 years; range, 41–75 years), who were followed for at least 5 years (mean observation period, 91 months; range, 60–195 months), were included in this series, and as the method of NB reconstruction, the modified Studer, Hautmann, Mainz, Goldwasser and Reddy types of NB were created in 36 (31 male; five female), nine (eight male; one female), 15 (13 male; two female), 10 (10 male; 0 female) and 19 (16 male; three female), respectively. None of the patients had presented with any voiding dysfunction before surgery and all were free of cancer at the analysis for this study.
In this series, all of the following examinations were carried out more than 5 years after surgery. Voiding pattern and continent status in each patient were evaluated using a questionnaire. Since there were no patients with permanent catheterization, voiding status was classified into the following three categories: voiding with no assistance, voiding with clean intermittent catheterization (CIC) and voiding with CIC alone. At our institutions, CIC was recommended for patients with post-void residual urine volume greater than 100–150 mL. Patients were regarded as continent when they were dry without protection, and patients who could remain dry at night if they voided at regular intervals were also considered continent.
A free uroflowmetry was carried out for 82 patients who could void with no assistance or void with CIC assistance approximately 3 h after the previous urination. After this examination, patients were catheterized to empty the NB and determine the post-void residual. Serum levels of chloride and creatinine as well as blood gases, including pH, bicarbonate and base excess, were measured in these 82 patients.
Differences between the groups were analyzed by the χ2 test or the nonparametric Mann-Whitney U test using StatView 5.0 software, and P < 0.05 was defined as significant.
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Of the 89 patients included in this study, 67 (75.3%) could void spontaneously, whereas 15 (16.8%) voided with CIC assistance and seven (7.9%) with CIC alone. However, there was no significant difference in the voiding status among patients with the modified Studer, Hautmann, Mainz, Goldwasser and Reddy types of NB (Table 1).
Table 1. Comparison of voiding status according to the type of neobladder reconstruction
|Type of neobladder†||Voiding with no assistance (%)||Voiding with CIC assistance (%)||CIC alone (%)|
|Modified Studer type (n = 36)||27 (75.0)||7 (19.4)||2 (5.6)|
|Hautmann type (n = 9)||7 (77.8)||1 (11.1)||1 (11.1)|
|Mainz type (n = 15)||10 (66.7)||3 (20.0)||2 (13.3)|
|Goldwasser type (n = 10)||7 (70.0)||2 (20.0)||1 (10.0)|
|Modified Reddy type (n = 19)||16 (84.2)||2 (10.5)||1 (5.3)|
|Overall (n = 89)||67 (75.3)||15 (16.8)||7 (7.9)|
We then evaluated the continent status in 82 patients after excluding seven who voided with CIC alone. As shown in Table 2, daytime and night-time continence was achieved in 63 (76.8%) and 50 (61.0%) patients, respectively. The proportion of daytime continence in the modified Studer NB group was significantly greater than that in the Mainz NB group, whereas there was no significant difference in the proportion of night-time continence among the five groups.
Table 2. Comparison of continence status according to the type of neobladder reconstruction
|Type of neobladder||Daytime continence (%)||Night-time continence (%)|
|Modified Studer type (n = 34)||30 (88.2)†||24 (70.6)|
|Hautmann type (n = 8)||6 (75.0)||6 (75.0)|
|Mainz type (n = 13)||7 (53.8)†||6 (46.2)|
|Goldwasser type (n = 9)||8 (88.9)||5 (55.6)|
|Modified Reddy type (n = 18)||12 (66.7)||9 (50.0)|
|Overall (n = 82)||63 (76.8)||50 (61.0)|
The outcomes of a free uroflowmetry carried out in these 82 patients are presented in Table 3. There were no significant differences in the maximal flow rate and the voided volume among the five groups; however, the post-void residual in the modified Reddy NB group was significantly smaller than that in the modified Studer NB group.
Table 3. Comparison of voiding function according to the type of neobladder reconstruction
|Type of neobladder||Maximal flow rate (mL/second)||Voided volume (mL)||Post-void residual (mL)|
|Modified Studer type (n = 34)||18.5 ± 12.1||234.3 ± 102.8||68.7 ± 131.3†|
|Hautmann type (n = 8)||14.5 ± 10.8||244.6 ± 149.8||48.8 ± 68.1|
|Mainz type (n = 13)||16.9 ± 11.1||297.6 ± 281.4||27.3 ± 32.3|
|Goldwasser type (n = 9)||11.2 ± 6.6||235.1 ± 53.3||91.0 ± 178.0|
|Modified Reddy type (n = 18)||16.6 ± 8.8||216.7 ± 120.9||23.7 ± 51.9†|
|Overall (n = 82)||16.6 ± 10.7||241.6 ± 183.3||52.8 ± 108.8|
The blood chemistry profile in these 82 patients showed that the mean values of examined parameters, including pH, bicarbonate, chloride, base excess and creatinine, in each group were within their normal ranges. In addition, there were no significant differences in the pH, bicarbonate, chloride and base excess among the five groups, whereas the serum level of creatinine in the modified Reddy NB group was significantly lower than those in the modified Studer NB and Hautmann NB groups (Table 4).
Table 4. Comparison of blood chemistry profile according to the type of neobladder reconstruction
|Type of neobladder||pH||Bicarbonate (mEg/L)||Chloride (mEq/L)||Base excess (µmol/L)||Creatinine (mg/dL)|
|Modified Studer type (n = 34)||7.39 ± 0.038||24.1 ± 2.6||107.0 ± 3.2||−0.54 ± 2.75||0.96 ± 0.22†|
|Hautmann type (n = 8)||7.36 ± 0.033||23.1 ± 1.9||105.8 ± 3.1||−1.24 ± 2.11||1.11 ± 0.34†|
|Mainz type (n = 13)||7.37 ± 0.037||24.2 ± 3.4||106.2 ± 3.7||−0.96 ± 3.22||0.91 ± 0.24|
|Goldwasser type (n = 9)||7.36 ± 0.039||23.8 ± 1.4||107.6 ± 4.7||−1.76 ± 1.97||0.97 ± 0.27|
|Modified Reddy type (n = 18)||7.36 ± 0.038||24.1 ± 2.6||107.0 ± 3.2||−0.54 ± 2.75||0.90 ± 0.59†|
|OVerall (n = 82)||7.37 ± 0.039||23.8 ± 3.0||107.1 ± 3.4||−0.97 ± 2.6||0.95 ± 0.35|
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Functional outcomes, such as voiding pattern and continent status, following the reconstruction of intestinal orthotopic NB have been extensively investigated in the literature; however, there have been few reports comparing long-term functional outcomes among patients receiving different types of orthotopic NB creation.3–5 At our institutions, since 1983, orthotopic NB replacement after radical cystectomy has been carried out in more than 400 patients with invasive bladder cancer, and the preferred types of NB have changed during this period.9–18 In this study, therefore, we retrospectively analyzed the data associated with functional outcomes of 89 patients who underwent orthotopic NB reconstruction after radical cystectomy and were followed for at least 5 years in order to characterize differences in functional outcomes among several types of NB created at our institutions.
Initially, we would like to describe the limitations of this series. The number of patients in each group was small; that is, this study included 36, 9, 15, 10 and 19 patients with modified Studer, Hautmann, Mainz, Goldwasser and modified Reddy types of NB, respectively. Although the functional outcomes after NB reconstruction are quite different between male and female patients, this study simultaneously analyzed the outcomes irrespective of the difference of gender because of the small proportion of female patients in each group. Furthermore, several surgeons at our institutions carried out radical cystectomy and NB creation, and details of the procedures, such as the length of intestinal segment used for NB and the anti-reflux technique, slightly differ even within the same group. The interval between surgery and the assessment of functional outcomes for this study in each patient also varied. Collectively, these findings suggest that it would be absolutely necessary to increase the number of patients in each group and to carry out functional examinations within a uniform interval after surgery to draw definitive conclusions concerning the issues evaluated in this study.
In the present series, despite the lack of significant differences in the voiding status among the five groups examined, the modified Reddy type exhibited the most favorable voiding status showing a proportion of spontaneous voiders greater than 80%. These findings were supported by several previous studies.3,4,19 For example, Laguna et al. reported that all 50 patients with sigmoid NB were able to void spontaneously throughout the observation period of at least 5 years.19 In addition, some investigators showed that the number of patients with ileal NB who needed CIC tended to increase with time,12,20 which could be possibly explained by the weak contraction of ileal NB due to the overextension of the thin ileal wall. Accordingly, long-term monitoring should be carried out in patients with NB, particularly those with ileal NB, because deterioration of the voiding status takes time to develop in these patients.
Continence status is one of the strongest factors affecting the patient's postoperative satisfaction.3 According to the reported outcomes in several large series, the incidence of daytime continence in patients with NB was 80–100%, whereas the night-time continence rate ranged between 66% and 97%.3,6,7,21 In this series as well, the daytime continence in each group was superior or similar to the night-time continence. Furthermore, a significant difference was observed in daytime continence only between the modified Studer and Mainz types of NB; however, the continence status in patients with either modified Studer or Hautmann types of NB tended to be more favorable than those with other types of NB, and this difference during night-time was more remarkable than that during daytime. Because the definitions of continence vary among studies, it is difficult to simply compare outcomes among different studies on this issue. However, the previously reported outcomes of continence status in patients with NB were generally consistent with the present result; that is, patients with ileal NB achieved better continence status, particularly during the night-time, than those with sigmoid NB.3–5
It would also be of interest to compare the long-term outcomes of free uroflowmetry according to the type of NB. In this series, there were no significant differences in the maximal flow rate and voided volume among the five groups, while the post-void residual in the modified Reddy type was significantly smaller than that in the modified Studer group. However, the post-void residual volume according to the type of NB remains controversial. For example, Schrier et al. showed that a post-void residual higher than 100 mL was observed in 24% of patients with a sigmoid NB and in 10% of those with an ileal NB,5 whereas Kato et al. reported a greater post-void residual volume in the sigmoid NB group than in the ileal NB group.4 These conflicting results might be explained by different intervals between surgery and uroflowmetry analysis in each study; that is, despite a lack of significant changes in the post-void residual urine volume over time in the sigmoid NB, post-voided residual volume increases in a time-dependent manner in ileal NB.3,4
Although voiding function in patients with NB have shown dynamic changes over time according to the type of NB, the long-term metabolic status was well preserved in all types of NB, showing that the mean values of evaluated parameters in each group were within the normal ranges. Of all factors examined, significant differences were observed only in serum levels of creatinine between patients with the modified Reddy type of NB and those with the modified Studer and Hautmann types of NB, which may reflect the difference in voiding status, particularly the post-void residual volumes, among these groups.
To overcome the problem associated with the small number of patients in each group, we divided the included patients between the ileum type (i.e. the modified Studer and the Hautmann NBs) and the colon type (i.e. the Mainz, the Goldwasser and the modified Reddy NBs) groups, and re-analyzed the outcomes according to this classification. The proportion of night-time continence in the ileum type NB group was significantly greater than that in the colon type NB group, whereas the serum level of creatinine in the colon type NB group was significantly lower than that in the ileum type NB group. However, there were no significant differences in the remaining parameters evaluated between these two groups.
In conclusion, at least 5 years after surgery, orthotopic NB created with intestinal segments generally demonstrated acceptable functional outcomes; however, these outcomes differed according to the types of NB replacement. Therefore, it is necessary to properly understand the long-term functional prospects, on which the subjective success of orthotopic NB creation may largely depend, in order to determine the optimal procedure for NB reconstruction.