Orthotopic neobladder reconstruction what are the options?

Transcription

1 Minirev Article ORTHOTOPIC NEOBLADDER RECONSTRUCTION MEYER et al. Orthotopic neobladder reconstruction what are the options? JON-PAUL MEYER, DEREK FAWCETT*, DAVID GILLATT and RAJENDRA PERSAD Department of Urology, Wycombe General Hospital, High Wycombe, *Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading, Southmead Hospital, Westbury-on-Trym, and United Bristol Healthcare Trust, Bristol, UK Accepted for publication 4 February 2005 KEYWORDS radical cystectomy, orthotopic neobladder reconstruction, continent urinary diversion. INTRODUCTION The standard treatment for urinary diversion has been the ileal conduit, but in the last decade and a half, efforts have been made to preserve patient body image and quality of life by constructing continent bladder substitutes [1]. An orthotopic neobladder shares several normal bladder characteristics, which include a continence mechanism, adequate capacity at a low intravesical pressure and an antireflux mechanism to prevent upper tract dilatation [1]. Lemoine in 1913 [2] was credited with the first orthotopic reconstruction in a human. The patient initially underwent cystectomy and ureteric re-implantation into the rectum. Because of recurrent episodes of pyelonephritis the patient had a second procedure whereby the rectal segment was isolated and anastomosed onto the native urethra. The sigmoid colon was then reanastomosed to the anus. In 1979 Camey and Le Duc [3] reported their experience of creating a neobladder from small intestine, with preservation of the urethral sphincter mechanism at cystectomy, and by doing so showed that this procedure was feasible. Several methods of neobladder construction have since been reported [4 7]. Although the results were initially encouraging, before 1990 orthotopic neobladder reconstruction (ONR) was reserved for male patients. The procedure was initially contraindicated in females as the native urethra was routinely removed during a female cystectomy (as this was thought to provide adequate resection margins), and it was thought that the female patient would be unable to maintain an appropriate continence mechanism after ONR. There is now a better understanding of the anatomy of the female continence mechanism, and anatomical dissection supports the idea that the continent outlet is preserved after orthotopic reconstruction [8]. It has now been reported that, in most women, the proximal urethra containing all the urethral transitional cell epithelium (distally it is mostly squamous epithelium) can be removed during cystectomy whilst still providing an adequate resection margin [9]. Continent urinary diversion via an ONR offers distinct advantages over an ileal conduit. These include the potential for near-normal voiding, continence, easier urethral surveillance with a lowered urethral recurrence rate, and a better body image [10]. In many centres worldwide, ONR has replaced the ileal conduit as the standard form of reconstruction. Despite this, ONR tends to be reserved for selected patients partly because the procedure is perceived to be technically difficult and associated with a higher rate of both perioperative and long-term morbidity. PATIENT SELECTION All suitable patients scheduled for cystectomy should have the option of ONR. Any interested patient should be carefully counselled and where possible have the opportunity to meet other patients who have had an ONR. Careful selection of patients before surgery is required to ensure that they are sufficiently motivated to comply with voiding re-education and long-term urethral follow-up. Contraindications to ONR are tumour in the prostatic urethra, other urethral diseases such as stricture, lack of understanding and motivation, body habitus, and rare local anatomical conditions such as shortness of the mesentery (discovered during surgery) and inflammatory bowel disease (e.g. Crohn s disease) affecting the chosen segment [10]. SHOULD PATIENTS AT HIGH RISK OF PELVIC RECURRENCE BE CONSIDERED FOR ONR? Hautmann et al. [11] considered the effect of local recurrence on neobladder function and survival in a series of 357 men. Each patient had a radical cystectomy and ileal neobladder substitution. The authors reported 43 local recurrences in this group (12%), of whom 36 had locally advanced disease (stage pt3a or greater, or node-positive) on histological examination of the cystectomy specimen. Of the 43 men, 40 maintained good neobladder function, and only one required the neobladder be removed, because of an intestinal fistula. The authors concluded that most patients may anticipate normal neobladder function even in the presence of recurrent disease or until death. Similar results have been found by other groups [12,13]. Studies such as these support the notion that it is safe and appropriate to use ONR after radical cystectomy in patients with locally advanced disease who meet the aforementioned criteria about motivation and fitness. ONR AFTER PREVIOUS PELVIC RADIOTHERAPY Gschwend et al. [14] reported on complications after ONR in patients who had previously received pelvic radiation. In that study, 11 patients had a salvage cystectomy and ONR; and the complication rate was similar to that of a control group of unirradiated patients. The authors concluded that previous pelvic irradiation should not be a primary contraindication for ONR. Bochner et al. [15] reported on 18 patients who had salvage surgery and ONR after failed radical pelvic radiotherapy. Again, complication rates were similar between irradiated and unirradiated groups, but continence rates were low (67% day and 56% night-time) BJU INTERNATIONAL 96, doi: /j x x 493

2 MEYER ET AL. Artificial urinary sphincters were placed in 22%. Clearly these reports were of few patients and further studies are required. FIG. 1. The Studer neobladder. Salvage orthotopic reconstruction, although a very challenging procedure, might be viable in carefully selected patients, but very careful intraoperative tissue assessment is required to limit complications and provide the best clinical outcomes. In addition, patients should be informed that incontinence rates are substantial after salvage ONR and that an artificial urinary sphincter might be required in >20% of cases. THE PRINCIPLES OF CONTINENT URINARY DIVERSION The construction of a reservoir that can accommodate a large volume, under low pressure, and with a limited absorption of urinary constituents is critical to success. Important principles include: the configuration determining the capacity (volume = height radius 2 ), accommodation which relates pressure and volume to mural tension, i.e. Laplace s Law (T = P r 3 ), and compliance, which relates to the physical characteristics of the bowel wall [16]. To provide a continent urinary diversion the rhabdosphincter mechanism must remain intact, to provide a continent means of storing urine. TYPES OF ORTHOTOPIC NEOBLADDER The small intestine, terminal ileum and caecum, large intestine, or a combination of these, have been used to construct a urinary reservoir. The ileum is thought to provide advantages over other bowel segments, as it appears to be less contractile and more compliant, which might therefore provide better continence rates than orthotopic neobladders constructed from large bowel. There is evidence that the colon is less compliant and can store urine at higher pressures than the ileum [16]. In addition, it was reported that although the urodynamic profiles of an ileal neobladder show a similar volumetric capacity to colonic neobladders, the pressure at maximum capacity was much lower in the ileal neobladder [17]. The forms of orthotopic neobladder constructed at our institutions are the Studer type and the Hautmann W pouch, the reason for selecting these types of neobladder being personal preference. Isolated ileal segment opened distally to allow detubularisation THE STUDER This is an ileal bladder substitute with a long, afferent isoperistaltic tubular ileal segment which, following its description by Studer et al. [18], has become a very common form of continent urinary diversion (Fig. 1). The surgical technique used at our institution is similar to that proposed by Studer et al., whereby a portion of terminal ileum cm long is isolated ª25 cm from the ileocaecal valve. From this, a cm ileal segment is used to form the reservoir, with cm being used to construct the afferent tubular limb to which the ureters are anastomosed. HAUTMANN W POUCH Membranous urethra Pelvic floor muscles This form of neobladder is a large-capacity spherical ileal reservoir that is created in a W configuration [19]. It is formed by identifying a segment of terminal ileum of ª70 cm long; this segment is isolated and arranged in a W shape, and incised along its antimesenteric border. The four limbs of the W are then sutured to one another with a running suture, a segment of the ileal wall is then excised on the antimesenteric portion, which is then anastomosed to the urethra. The ureters are then implanted from inside the neobladder through a small incision (Fig. 2). In all cases we advocate the use of stents, catheters and drains. We use a 20 F Porjes neobladder catheter (this has a long stem distal to the balloon with many holes for drainage), thus allowing good drainage of mucus from the neobladder, bilateral ureteric Ureters joined to iso peristaltic segment of ileum Detubularised low pressure ileal neo bladder stents (Cook Bander set) which cross the uretero-ileal anastomosis and are externalized to the skin (usually removed 1 2 weeks after surgery), and two pelvic drains. In addition, patients have a nasogastric tube while the postoperative ileus settles. The choice of catheter and stents varies among surgeons, but it is essential that a clear postoperative protocol is given to the nursing staff to avoid any unnecessary complications such as mucus blockage of the catheter or the stents. Regular stent and catheter flushes are recommended. METABOLIC COMPLICATIONS OF URINARY DIVERSION Whenever intestine is interposed in the urinary tract there is the potential for several metabolic sequelae. These include electrolyte abnormalities, altered drug metabolism which might result in altered sensorium, infection, osteomalacia, growth retardation, calculi, short-bowel syndrome, cancer, and altered bile metabolism. The most significant metabolic complication is electrolyte imbalance, and the exact abnormality depends on the segment of bowel used. If ileum and colon are used, a hyperchloraemic metabolic acidosis might occur, and if jejunum is used, a hypochloraemic, hyperkalaemic metabolic acidosis might result. The acidosis which develops might result in electrolyte abnormalities, osteomalacia, altered hepatic metabolism, renal calculi and abnormal drug metabolism. However, generally patients with BJU INTERNATIONAL

3 ORTHOTOPIC NEOBLADDER RECONSTRUCTION FIG. 2. The Hautmann W pouch. minimal manipulation of the muscle fibres, fascial attachments and innervation of the rhabdosphincter. Nerve-sparing procedures improve not only subsequent potency but also continence, probably by preserving the innervation of the smooth muscle component of the external sphincter. normal renal and hepatic function are less prone to acidosis and/or its complications. The key to the mechanism of acidosis is the transport of ammonium. Normally, the gut has transporters which are antiports for sodium/hydrogen ions and chloride/ bicarbonate ions; these antiports exchange one ion for another. Acidosis results from the substitution of ammonium for sodium in the sodium/hydrogen antiport, resulting in the translocation of an ammonium ion into the intestinal cell with the expulsion of a proton into the lumen of the gut. To maintain electrical neutrality, there is movement of chloride into the cell with expulsion of bicarbonate ions. This leads to the net absorption of ammonium chloride and excretion of carbonic acid. The treatment of the metabolic acidosis is straightforward. Bicarbonate or Bicitre solution (sodium citrate and citric acid) may be used, or Polycitra which is a combination of potassium citrate, sodium citrate and citric acid can also be used. THE RESULTS OF ONR Despite the advantages of a superior body image and the potential for near-normal voiding, ONR is perceived to be more technically demanding and associated with both greater mortality and morbidity than an ileal conduit. The published evidence does not appear to support this perception. Gburek et al. [20] compared the clinical outcomes of an orthotopic ileal neobladder (Studer type) and an ileal conduit in terms of peri-operative and long-term morbidity. They concluded that the orthotopic ileal neobladder is a safe procedure with similar peri-operative and long-term morbidity to an ileal conduit. Patients with other comorbidities that increase their anaesthetic risk are dissuaded from ONR, in theory to decrease their chances of re-operation and complications during and after surgery. Again, there is no supporting evidence for this theory; the re-operation rate for an ileal conduit is 10 14% [20,21] and that for an orthotopic ileal neobladder 8 15% [20,21]. The mortality rate for cystectomy and ileal conduit formation is <2% [22,23], and again this is similar to that associated with ONR, which in one series was 1% [10]. CONTINENCE After ONR, continence is probably influenced by the characteristics of the reservoir (large capacity and low pressure) and the rhabdosphincteric mechanism. Essential to maintaining continence after ONR is the In patients with an orthotopic neobladder, voiding via the native urethra is initiated by abdominal straining. It is generally thought that radical cystectomy abolishes the normal reflex rise in urethral pressure during reservoir filling [24], and therefore patients with orthotopic neobladders determine the time to void by a feeling of abdominal fullness or by following a strict regimen of voiding by the clock every 4 6 h (because of the poorly localized feeling of bladder discomfort at capacity). To ensure complete neobladder emptying, patients are encouraged to double void. Those who void by the clock set an alarm to awaken and empty their neobladders once at night. After ONR the reported daytime continence rates are 92 99% [1,10,22], with continence defined as freedom from needing pads for protection. The reported nocturnal continence rates are 74 83% [1,10,22]. At our institution, the median time to achieving full continence was 4 months [10]. URETHRAL RECURRENCE AFTER ONR There is concern about possible urethral recurrence after ONR, and this is cited as a deterrent for not using ONR. It is generally considered that the overall risk of a urethral recurrence in men undergoing cystectomy is ª10% [25], and much lower in men undergoing ONR ( 4%), possibly because patients are carefully screened with urethral biopsies before and during surgery to exclude malignancy at the future anastomotic site [6,26], or as the continued use of the urethra in some way protects it. The urethra is generally surveyed using a combination of urethral cytology and urethroscopy after ONR. The standard treatment for a urethral recurrence is urethrectomy, followed by either construction of a catheterizable continent pouch or the formation of an ileal conduit. However, it was reported that urethral recurrence as carcinoma in situ after ONR can be treated successfully in 80% of cases by intraurethral BCG perfusion therapy [26]. The authors 2005 BJU INTERNATIONAL 495

4 MEYER ET AL. reported that papillary or invasive transitional cell urethral recurrence should continue to be treated with urethrectomy [26]. QUALITY OF LIFE The resulting quality of life is an important determinant for patients considering an ONR. Bladder substitutions have a cosmetically more appealing result than ileal conduits, as a urostomy appliance is not required. In addition, there are documented improvements in the quality of life when compared to an ileal conduit [27,28]. Yoneda et al. [27], using the Sickness Impact Profile questionnaire, reported that quality of life was better in the neobladder than the ileal conduit group, especially in terms of mental, physical and social functioning in daily life. CONCLUSION The vast majority of patients undergoing ONR are continent, avoiding the need for a cutaneous stoma or external urostomy appliance, thus helping them to retain their body image. A review of current publications shows that continence rates are excellent, with no greater morbidity and mortality than after the present standard treatment of an ileal conduit. Nevertheless, careful selection and counselling of the patients is required before surgery to ensure that they are sufficiently motivated to comply with voiding re-education and the long-term urethral follow-up. Patients satisfying the criteria for ONR should be considered for this form of treatment, and the orthotopic reservoir should now be considered with the ileal conduit as best practice in urinary diversion after radical cystectomy. CONFLICT OF INTEREST None declared. REFERENCES 1 Benson MC, Seaman EK, Olsson CA. The ileal neobladder is associated with a high success and low complication rate. J Urol 1996; 155: Lemoine G. Creation d une vessie nouvelle par un procede personnel après cystectomietotale pour cancer. J Urol Med Chir 1913; 4: Camey M, Le Duc A. 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5 ORTHOTOPIC NEOBLADDER RECONSTRUCTION and ileal bladder substitution. J Urol 2004; 172: Yoneda T, Igawa M, Shinna H, Shigeno K, Urakami S. Postoperative morbidity, functional results and quality of life of patients following orthotopic neobladder reconstruction. Int J Urol 2003; 10: Hobisch A, Tosun K, Kinzl J et al. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol 2000; 18: Correspondence: Jon-Paul Meyer, Urology, Churchill Hospital, Oxford, UK. jpmeyer@doctors.org.uk Abbreviations: ONR, orthotopic neobladder reconstruction BJU INTERNATIONAL 497