UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

Surgical complications following radical cystectomy and orthotopic neobladders in women
Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-Azab M, Ashamallah A, Ghoneim MA
Urology and Nephrology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
J Urol. 2008; 180: 206-10; discussion 210

  • Purpose: Orthotopic neobladders have become the standard of care after radical cystectomy in select women with bladder cancer. We report early and late complications in 192 patients. Although medical complications were important, they were not the focus of this study.
  • Materials and Methods: Between January 1995 and December 2003, 192 women with a mean age of 50.6 years received an orthotopic neobladder after radical cystectomy for bladder cancer. Standard radical cystectomy was done. Ileal reservoirs were used, mostly in the form of an ileal W-neobladder. We evaluated the patients for functional outcome, early and late complications, and treatment for these complications.
  • Results: Two patients (1%) died of pulmonary embolism 1 to 2 weeks after cystectomy. Followup was 6 to 125 months (mean 54). Early complications included hemorrhage requiring reexploration in 1 case, postoperative blood transfusion in 1, wound infection in 8, prolonged ileus in 5, deep vein thrombosis in 5, pouch-vaginal fistula in 6, prolonged urinary leakage in 3, pouch-cutaneous fistula in 1 and early ureteral obstruction in 1. Of the 177 patients eligible for functional evaluation 62 experienced a total of 75 late complications, including stone disease in 18, ureteroileal stricture in 19, reflux in 22, intestinal obstruction in 2, incisional hernia in 2 and chronic pyelonephritis in 12. Early and late complications were treated accordingly with good outcomes.
  • Conclusions: Early and late complications develop in a significant number of patients. Most early complications may be treated conservatively, while late complications are mostly treated with endourological and/or open surgery. Close lifelong surveillance of patients is mandatory to detect and properly treat these complications.

  • Editorial Comment
    Bladder cancer and its treatment with the specific anatomical aspect became a growing issue for women in recent years (1). The ileum conduit and the continent cutaneous pouch seemed to be the only option for female patients; whereas the ileum orthotopic neobladder was already the common surgical treatment for males. In the female, the different anatomical continence mechanism within the muscular pelvis had to be considered. A solution came from one of the centers with a high cystectomy frequency for both sexes where the orthotopic neobladder was performed in the early phase (2).
    Ali-El-Dein B et al. (3) published the short and long-term follow-up of 192 women who received a orthotopic ileum neobladder during the time period 1995 - 2003. The complications were primarily noted in the upper urinary tract and mostly caused by implantation strictures within the first two years after the surgery. The complications experienced are similar to others, independent to the sex. As recently noted by the Consensus Conference on Bladder Cancer of the World Health Organization (WHO), this issue cannot be solved by a single suggestion (4).
    Increased knowledge of the pelvic anatomy helped to reduce, as the authors stated, the frequency of neobladder-vaginal fistula described by Stenzl (5). Although the presented data includes those with the technique of orthotopic neobladder of an early period, the continence rate is similar to others (6).
    The growing anatomical knowledge results in better intraoperative identification and preservation of the sphincteric area and neurovascular structures thus improving the long-term outcome and satisfaction (7).

References
1. Stenzl A: Current Concepts for Urinary Diversion in Women. EAU-EBU, Update Series. 2003; 1: 91-9.
2. Abol-Enein H, Ghoneim MA: Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol. 2001; 165: 1427-32.
3. Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-Azab M, Ashamallah A, Ghoneim MA: Surgical complications following radical cystectomy and orthotopic neobladders in women. J Urol. 2008; 180: 206-10; discussion 210.
4. Hautmann RE, Gschwend JE, de Petriconi RC, Kron M, Volkmer BG: Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J Urol. 2006; 176: 486-92; discussion 491-2.
5. Stenzl A, Nagele U, Kuczyk M, Sievert KD, Anastasiadis A, Seibold J: et al.: Cystectomy - Technical Considerations in Male and Female Patients. EAU-EBU, Update Series, 2005; 3: 138-46.
6. Nagele U, Kuczyk M, Anastasiadis AG, Sievert KD, Seibold J, Stenzl A: Radical cystectomy and orthotopic bladder replacement in females. Eur Urol. 2006; 50: 249-57.
7. Schilling D, Horstmann M, Nagele U, Sievert KD, Stenzl A: Cystectomy in women. BJU Int. 2008; 102: 1289-95.

Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de