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 |