RECONSTRUCTIVE UROLOGY

Neuromodulatory Therapies in Female Pelvic Medicine and Reconstructive Surgery: Biological Agents
Schulte-Baukloh H, Knispel HH
Department of Urology, St. Hedwig Hospital, Teaching Hospital of University Hospital Charite, Berlin, Germany
BJU Int. 2006; 98 Suppl 1: 50-60; discussion 61

• In recent years, important improvements in the management of patients with neurogenic or non-neurogenic detrusor overactivity and urge incontinence have been brought about by the introduction of vanilloids and botulinum toxins in urology. In this review we introduce the new therapeutic options, provides basic information, and summarize the results experienced so far.

Neobladder Emptying Failure in Males: Incidence, Etiology and Therapeutic Options
Simon J, Bartsch G Jr, Kufer R, Gschwend JE, Volkmer BG, Hautmann RE
Department of Urology, University of Ulm, Ulm, Germany
J Urol. 2006; 176: 1468-72; discussion 1472

• Purpose: Neobladder reconstruction is considered the best option for patients requiring cystectomy. Limited information is available about incidence, etiology and therapeutic options for neobladder emptying failure in males.
• Materials and methods: In a retrospective study we analyzed the data of a consecutive series of 655 male patients (age range 23 to 82 years, median 63; followup range 0 to 208 months, median 36.5) who received an ileal neobladder following radical cystectomy at our institution. All patients had a complete followup until death or until December 2003. Data on all diagnostic and therapeutic procedures performed for neobladder emptying failure were collected.
• Results: Of 655 patients 75 (11.5%) had at least 1 episode of failure emptying the neobladder requiring some form of therapy during followup. Failure was due to dysfunctional voiding in 23 patients (3.5%) and mechanical obstruction in 52 patients (8%). Causes of mechanical obstruction were benign strictures of the neovesicourethral anastomosis (23 patients, 3.5%) or the anterior urethra (11 patients, 1.7%), neoplastic obstruction by local tumor recurrence (13 patients, 2.0%) or a nonurological malignancy (1 patient, 0.2%), and obstruction by mucosal valves (3 patients, 0.5%) or a foreign body (1 patient, 0.2%). In 38 of 52 patients with mechanical obstruction of the neobladder outlet emptying was fully restored with endourological procedures, while in 14 of 52 patients long-term catheterization was necessary. Catheterization was the therapy of choice for all patients with dysfunctional voiding.
• Conclusions: Neobladder emptying failure is of major concern but is not an argument against orthotopic diversion. The overall rate of transient or permanent neobladder emptying failure in males is high but most of the mechanical causes can be managed endoscopically, while the rate of patients with long-term catheterization for dysfunctional voiding is relatively low.
  
  
• Editorial Comment
  The authors report on the emptying problems in their vast experience in male patients with an orthotopic neobladder. 75 of 655 patients (11, 5%) had problems with emptying of the neobladder requiring therapy after follow up of up to 208 months. The biggest group of patients were those with a stricture of the neovesicoureteral anastomosis (3, 5%) followed by a local tumour recurrence (2, 0%) and urethral strictures (1, 7%). In the recent literature with six major retrospective publications who analyzed this issue, a rate of outlet obstruction, mainly as anastomotic strictures was found in 4.5 – 17.5% within 6 – 8 months after the surgery. Compared to these data, the authors have only 3.5% of anastomotic strictures, which is at the lower end.
  The good message about the report of these problems is that the majority of patients did regain volitional voiding, generally after one endoscopic treatment (with the exception of pelvic tumour recurrences). This led to the conclusion by the authors that despite a fairly large emptying failure in this series most of these problems were of mechanical origin and could thus be managed endoscopically.
  It is of note, too, that apparently none of the anastomotic tumor recurrences was treated either surgically or by radiotherapy. One can speculate that the anastomotic tumour recurrences were a consequence of a more cranial pelvic recurrence. It may, however, also have been possible that due to the omission of endoscopy during the follow up a recurrence was only diagnosed at a time when surgery was not a possibility anymore.
  From this large series one can also see that a neobladder valve obstructing the outlet can be found in male patients as well. We have seen and published obstructing ileal valves as a possible reason of urinary retention in female patients. Obstructing ileal valves seem to be a possibility in male patients as well and are leading to the same therapeutic consequence, i.e. transurethral valve resection (1). The similar observation in male patients was seen with dysfunctional voiding: It was present in 2% of male patients and almost always led to long term catheterization.
  Altogether a nice series of a not so rare problem in both male and female neobladder patients. For those performing such a procedure and those dealing with these patients during follow up it is definitely a recommendable manuscript.

References
1. Stenzl A, Colleselli K, Bartsch G: Update of urethra-sparing approaches in cystectomy in women. World J Urol. 1997; 15: 134-8.

Dr. Arnulf Stenzl & Dr. Karl-Dietrich Sievert
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany