Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocaecal and Ileal Neobladder $

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1 European Urology European Urology 43 (2003) 258±262 Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocaecal and Ileal Neobladder $ YasËar BeduÈk, Kadir TuÈrkoÈlmez, SuÈmer Baltacõ, CËagÆatay GoÈgÆuÈsË * Department of Urology, Ankara University, School of Medicine, Ankara, Turkey Accepted 7 January 2003 Abstract Objective: Aim of this study was to evaluate the clinical and urodynamic results in patients who had undergone orthotopic bladder substitution with ileocaecal (Mainz pouch procedure) or ileal (Abol-Enein and Ghoneim procedure) segments and who had a minimum follow-up of 12 months. Methods: Mainz pouch procedure (MP) was performed in 19 patients (mean age 62.4 years, median follow-up 36 months) and Abol-Enein and Ghoneim procedure (AG) in 36 patients (mean age 64.3 years, median follow-up 31 months). Complications and urodynamic ndings were compared in both groups. Results: Complications related to the pouch were (MP and AG groups, respectively) ureterointestinal anastomotic stenosis (10.5% versus 5.7%), poucho-urethral anastomosis stenosis (5.3% versus 5.5%), poucho-ureteral re ux (7.9% versus 4.2%), and pyelonephritis (15.8% versus 13.8%). At 12 months postoperatively, daytime incontinence rates were 5.3% versus 5.5% and nighttime incontinence (twice weekly or more) rates were 21% versus 8.4% in MP and AG groups. In urodynamic evaluation, which was performed in 39 patients at 12 months postoperatively, both groups showed adequate bladder capacity, the mean values of which were ml in MP group and ml in AG group ( p > 0:05). The mean value of maximal ow rate was 19:6 3:7 ml/s in MP group and 16 6:1 ml/s in AG group ( p > 0:05). The mean residual urinary volume was 37 8:2 ml in MP group and 45 7:1 ml in AG group ( p > 0:05). Conclusion: The comparison between two types of bladder substitution, namely ileocaecourethrostomy (Mainz pouch procedure) and ileal reservoir (Abol-Enein and Ghoneim procedure) has demonstrated that urodynamic ndings showed no signi cant difference between two groups. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Urinary diversion; Orthotopic reconstruction; Bladder substitution; Cystectomy 1. Introduction Many techniques for orthotopic neobladder construction have been described, and a variety of modi cations have been performed to improve on the basic concept of a low-pressure, compliant urinary reservoir designed to protect the upper urinary tracts and preserve volitional voiding per urethra. Various segments $ The work has been presented on XVIIth EAU Congress, Birmingham, February 23±26, 2002 (oral presentation, 642). * Corresponding author. Current address: Mahatma Gandhi Caddesi, 46/3, GaziosmanpasËa, Ankara 06700, Turkey. Tel ; Fax: address: cgogus@tr.net (CË. GoÈ gæ uè së). of small and large bowel have been used for neobladder construction. The choice of bowel segment is in uenced by the physical characteristics of bowel, the technical simplicity of neobladder construction and the extent of metabolic sequele. The ileocaecal (Mainz) pouch technique was originally described by ThuÈroff et al. [1]. Satisfactory results of bladder substitution with ileocaecal pouch have been reported [2,3]. Ileal neobladder construction with serous-lined ureteral reimplantation was described by Abol-Enein and Ghoneim [4±7]. Good functional outcome of this technique was reported by these authors [8] and by others [9±11] /03/$ ± see front matter # 2003 Elsevier Science B.V. All rights reserved. doi: /s (03)

2 Y. BeduÈk et al. / European Urology 43 (2003) 258± We report here the clinical and urodynamic results of these two types of orthotopic neobladders. 2. Patients and methods Sixty-three consecutive patients underwent radical cystoprostatectomy for invasive bladder carcinoma and orthotopic neobladder creation at our institution between 1995 and Only patients with a minimum follow-up of 12 months were included into the study. Fifty- ve patients met this criterion and formed the basis of this study. Two different techniques of bladder substitution were performed in these patients. In 19 patients, with a mean age of 62.4 years, the bladder substitution was obtained with an ileocaecal segment (Mainz pouch [MP]). In 36 patients, with a mean age of 64.3 years, an orthotopic bladder substitution was achieved by means of an ileal reservoir (Abol-Enein and Ghoneim technique [AG]). The type of neobladder was determined primarily by the surgeon preference. Patient characteristics are presented in Table 1. Ileocaecal bladder substitution (MP) was constructed as described by ThuÈroff et al. [1], from 10 cm to 15 cm segments of caecum and ascending colon and two contiguous 10±15 cm segments of terminal ileum. Detubularization and recon guration of the bowel was made. The ureters were implanted into the caecum by submucosal tunnels and stented with double-j catheters. The double-j stents were removed cystoscopically after 2 months. Orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation was constructed as described by Abol-Enein and Ghoneim [4±7]. The reservoir was constructed from a 40 cm to 50 cm segment of distal ileum. The isolated segment was arranged into a w-shaped con guration. The ureters were implanted using the serous-lined extramural tunnel technique. Double-j stents were used in all patients. The double-j stents were removed cystoscopically after 2 months. After hospital discharge the patients were scheduled for monthly follow-up visits for the rst 3 months and at 3-month intervals for the rst year. During follow-up the patients underwent routine laboratory investigations, excretory urography (IVP), cystography, ascending studies and computerized tomography (CT) at 6 and 12 months and then once yearly. Patient evaluation also included symptom analysis for continence status and voiding frequency. Daytime and nighttime continence was assessed by patient interview at 12 months. Patients were considered continent if they did not use pads or no more than one pad was required during the day or night. Nighttime continence was assumed when the patient slept through the night or awakened no more than two or three times to void without urine leakage. Nighttime continence was classi ed according to the frequency of bedwetting (completely dry, less than twice weekly and twice weekly or more). Urodynamic evaluation was performed in 39 patients (14 in MP, 25 in AG group) at 12 months postoperatively using a urodynamic machine with uoroscopic monitoring. Nine patients (three in MP and six in AG group) Table 1 Patient characteristics Mainz pouch group Abol-Enein and Ghoneim group Number of patients Mean patient age (years) 62.4 (47±69) 64.3 (42±71) Median follow-up (months) 36 (12±69) 31 (12±47) refused urodynamic testing and seven patients (two in MP and ve in AG group) who had urodynamic analysis in another medical center were not included for urodynamic evaluation. The neobladder was lled at the standard rate of 20 ml per minute with dilute contrast material. Maximal capacity was calculated at the point of discomfort, leak or 600 cc. In addition, at 80% reservoir capacity the highest pressure spikes above baseline due to spontaneous pouch contractions were recorded. Compliance was calculated at maximum capacity by the formula; change in volume (ml) divided by change in baseline pressure (cm H 2 O). In addition, pressure at maximum capacity (cm H 2 O) was compiled and a mean value was obtained. Uro owmetry was done and postvoid residual urine volume was also estimated. Results were reported as mean and range. Fisher's exact, w 2 and Student's t-tests were used for statistical analysis. p < 0:05 was de ned as statistically signi cant. 3. Results The median follow-up of the 19 patients with ileocaecal neobladder was 36 months (range, 12±69 months). The median follow-up period was 31 months (range, 12±47 months) in 36 patients with ileal neobladder. Of the 19 patients in MP group, 2 died of metastatic tumor at 22 and 26 months postoperatively. Of the 36 patients in AG group 2 patients died of metastatic tumor at 19 and 26 months postoperatively and 1 died of myocard infarction at 38 months. In 55 patients, 108 ureterointestinal anastomosis were performed (38 in MP group and 70 in AG group). Two patients in AG group had solitary renal unit. Preoperatively, three renal units in MP group and ve renal units in AG group had dilated ureters. Complications related to the neobladder are presented in Table 2. Unilateral ureterointestinal anastomotic stricture developed in 4 of 38 (10.5%) renal units in MP group and 4 of 70 (5.7%) renal units in AG group. Strictures occurred within 6 months in two renal units (both in MP group), 6±12 months in ve (two in MP group and three in AG group) and at 24 months in one (AG group). In ve of these eight Table 2 Neobladder related complications MP group (n ˆ 19) (n) % AG group (n ˆ 36) (n) % Ureteroileal anastomotic (4) 10.5% (4) 5.7% stricture (unilateral) Ureteral re ux (unilateral) (3) 7.9% (3) 4.2% Poucho-urethral stricture (1) 5.3% (2) 5.5% Pyelonephritis (3) 15.8% (5) 13.8% Incontinence Daytime (1) 5.3% (2) 5.5% Nighttime Twice weekly or more (4) 21% (3) 8.4% Less than twice weekly (12) 63.2% (23) 63.8% Completely dry (3) 15.8% (10) 27.8%

3 260 Y. BeduÈk et al. / European Urology 43 (2003) 258±262 patients, treatment was necessary and consisted of ureterointestinal reimplantation in three (two in AG and one in MP group), retrograde dilatation in one (AG group) and nephrectomy in one (MP group). Renal function remained stable and the upper urinary tracts were unchanged in ultrasonography and/or excretory urography in these four patients who had ureterointestinal reimplantation or dilatation. In the remaining three patients ureterointestinal stenosis was mild and progressive detoriation of upper urinary tracts were not observed during follow-up. Unilateral re ux was present in 6 renal units (7.9% in MP group and 4.2% in AG group). In one ureter the re ux was grade III, while in the other ve ureters it was grade I or II. Reimplantation was not necessary in these renal units. Poucho-urethral stenosis developed in one case in MP group and in two patients in AG group. These stenotic complications occurred within 6±12 months. Endoscopic incision was performed in these cases. Signi cant pyelonephritis developed in eight cases ( ve in AG and three in MP group). Of these eight cases three had unilateral ureteral re ux and four had unilateral ureteroileal anastomotic stricture. All eight patients were treated with appropriate antibiotics. Continence rates were evaluated at 12 months postoperatively. During the day three patients (one in MP and two in AG group) were incontinent. At night, the frequency of bedwetting varied in the enuretic group (Table 2). Comparing the types of reservoir in the continent and enuretic groups revealed no statistically signi cant difference (Fisher's exact and w 2 -tests, p > 0:05). Additionally, neither improvement nor deterioration occurred in continence rates during further follow-up. Of the 55 patients 39 were evaluable with urodynamic studies at 12 months postoperatively (14 in MP group, 25 in AG group). Urodynamic data on both groups are shown in Table 3. Both groups showed Table 3 Urodynamic ndings in 39 patients MP (n ˆ 14) AG (n ˆ 25) Bladder capacity (ml) NS Compliance (ml/cm H 2 O) NS Pressure at maximum capacity NS (cm H 2 O) Maximal amplitude spontaneous NS pouch contraction (cm H 2 O) Maximal ow rate (ml/s) NS Postvoid residual urinary volume (ml) NS NS ˆ not signi cant. a Student's t-test. p a adequate bladder capacity. Comparing two groups, no signi cant differences were found with regard to mean bladder capacity, compliance, pressure at maximum capacity, maximal amplitude of spontaneous pouch contractions, maximum ow rates or mean postvoid residual urine volume (p > 0:05). 4. Discussion Since the introduction of the rst orthotopic neobladder for urinary diversion in patients undergoing radical cystectomy, multiple surgical techniques have been described in search of the ileal neobladder. Various segments of small and large bowel have been used for neobladder construction. The interest of many investigators has now focused on the question of which intestinal segment, and of what length is optimal for neobladder construction. Anastomotic stricture at the side of ureteroenteric implantation is among the most feared complication after urinary diversion, since another procedure usually is required to preserve the integrity and function of the upper urinary tract. The ideal ureteroileal anastomosis should be easy to construct and have a low incidence of stenosis. The reported incidence of ureterointestinal anastomosis stricture for Abol-Enein and Ghoneim technique is low and is less than 4% [8]. This incidence was 5.7% in our series. In a Mainz pouch series, the reported ureterointestinal anastomotic stricture rate was 7% while the collecting system was dilated after surgery in 16.6% [3]. Using MP for bladder substitution, Narayan et al. reported dilatation in 4 of 22 renal units and one patient required endourological intervention [2]. In our patients with Mainz pouch urinary diversion, ureterointestinal anastomotic stricture rate was 10.5%. According to literature and our ndings, although not statistically signi cant, ureterointestinal anastomosis with serous-lined extramural tunnel technique seems to have a lower ureterointestinal anastomotic stricture rate than ureterointestinal anastomosis with submucosal tunnel. We believe that the high failure rate of Mainz pouch implantation technique is due to technical dif culties of performing submucosal tunnels especially for dilated ureters. Preparing a serous-lined extramural tunnel is technically much more easier than performing a submucosal tunnel. As a matter of fact, serous-lined extramural tunnel technique can also be used in Mainz pouch urinary diversion to decrease the ureterointestinal anastomotic stricture rate. Controversy still exists on the question of whether an antire ux mechanism should be in corporated with the orthotopic neobladder. In MP and AG groups, different

4 Y. BeduÈk et al. / European Urology 43 (2003) 258± antire ux techniques were used. A submucosal tunnel and a serous-lined extramural tunnel techniques were used in MP and AG groups, respectively. Although Leissner et al. reported no re ux in 205 renal units with MP bladder substitution [3], we observed unilateral re ux in three patients (7.9%). However, in only one patient the re ux grade was III while the others had grade I re ux. On the other hand, Abol-Enein and Ghoneim reported a re ux rate of 3% in their series with serous-lined extramural ureteral reimplantation [8]. In our series, we observed unilateral grade II re ux in three patients (4.2%). We think that both techniques are quite effective for re ux prevention. However, we observed dif culty during ureterointestinal anastomosis of dilated ureters with submucosal tunnel technique (MP). In our hands serous-lined extramural tunnel technique is more suitable for the implantation of dilated ureters. The reported incidence of poucho-urethral anastomotic strictures in MP series was 14±27%. [2,3]. On the other hand this incidence was 1.5% in series of Abol- Enein and Ghoneim [8]. The high incidence of urethral anastomotic strictures in MP series must be attributed primarily to the surgical technique, by which a stump of appendix was anastomosed to the urethra. Leissner et al. noted anastomotic stricture in 7 of 13 patients in whom this technique was used [3]. In our patients, both in MP group and AG group, we performed urethroileal anastomosis after a button-hole incision and eversion of the intestinal mucosa. We observed one urethral anastomotic stricture in MP group and two in AG group and these were incised endoscopically. Pyelonephritis was often reported as a neobladder related early complication and the reported incidence of pyelonephritis in different series was 1±7.4% [3,12]. In our series pyelonephritis was observed as an early or late complication. The incidence of this complication was 15.8% and 13.8% in MP group and AG group, respectively. However, most of our patients with pyelonephritis had an underlying problem, either ureteral re ux or ureteroileal stenosis. Therefore, we think that pyelonephritis should be taken as an alarming complication and these patients should be evaluated after the acute episode for an underlying problem related to ureterointestinal anastomosis. The reported incidence of daytime continence in patients with an orthotopic bladder substitute was 88± 96% [3,8,12]. In our series daytime continence was excellent (94.7% in MP group and 94.5% in AG group). In regard to urinary continence, the greatest limitations of orthotopic bladder substitute have been with nighttime incontinence. Large series showed a nighttime continence rate of 44±85% [12±14]. This variation may be attributed to the adoption of different techniques. In our series 79% of patients in MP group and 91.6% of patients in AG group were dry or bedwetting less than twice weekly at night. Besides a fatigued external sphincter, we think that sleep results in an uncompensated decreased outlet resistance secondary to lack of a re ex arc that would normally signal a full bladder. In addition, Jakobsen and Steven demonstrated that normal nocturnal bowel activity contributed to nighttime incontinence of orthotopic reservoirs [15]. It would appear that a low intrapouch pressure is the most important factor in achieving nocturnal continence. In a study of urodynamic properties of a detubularized ileal pouch compared to the cecal pouch, Berglund et al. noted that cecal reservoirs had a signi cantly lower volume capacity and higher basal pressures at corresponding volumes. Furthermore, the motor activity was approximately 10 times greater in the cecal than in the ileal reservoir [16]. Our results revealed that, urodynamic data were not statistically different between MP and AG groups (p > 0:05). However, max amplitude spontaneous pouch contraction although not statistically signi cant was higher in MP group than in AG group and this nding may also help to explain why nighttime continence is slightly better in AG group than in MP group in our series. An ideal urinary reservoir is stable during storage of urine and the presence of unstable pouch contractions is surprising since all pouches were detubularized and recon gured. Observing spontaneous pouch contractions around 30 cm H 2 O in our ileal neobladder group (AG group) is even more surprising. However, like our experience, other investigators have also shown that detubularized ileal reservoirs have unstable contractions during the lling phase of urodynamics [17±20], but the mean pressures of these contractions was less than 40 cm H 2 O as in our AG group. In El Bahrasawy et al.'s study [20], in men with an orthotopic ileal reservoir, they reported mean values for maximal amplitude uninhibited contraction as cm and cm H 2 O in the continent and enuretic groups which are quite similar with our results. To our knowledge, the etiology of these contractions is speculative, although it may be associated with food intake. Lobel et al. noted that food intake triggers motor activity in the intestinal urinary reservoir similar to that of the duodenum [21]. Another possibility may be a higher concentration of these factors, which have yet to be de ned, in urine that induces such contractions. One factor that favors the ileal con guration over the ileocaecal pouch is the former with theoretically less diarrhea in those patients in whom even mild diarrhea would be unacceptable. This is particularly important

5 262 Y. BeduÈk et al. / European Urology 43 (2003) 258±262 in some paraplegic patients, those with bothersome diarrhea already or those with continent colostomies who do not wish to have signi cant changes in bowel function. However, bothersome diarrhea was not observed in our patients. In a study with Mainz pouch continent cutaneous diversion Stein et al. showed that vitamin B 12 serum levels began to decline only beyond 4 years after surgery and none of their patients developed clinical signs of vitamin B 12 de ciency [22]. Signi cant decline of vitamin B 12 serum levels was not observed in any patients in our groups. Finally, we should also emphasize that this is our rst personal experience with the two different techniques because the overall results are clearly dependent upon the surgeon's experience and his preferred technique. In conclusion, both ileal (Abol-Enein and Ghoneim) and ileocaecal (Mainz pouch) techniques seem to meet all of the prerequisites for an orthotopic neobladder for urinary diversion, including an uncomplicated surgical technique, a low complication rate and universal applicability. Comparison of urodynamic results did not reveal signi cant differences between the two techniques. References [1] ThuÈroff JW, Alken P, Riedmiller H, Engelmann U, Jacobi GH, Hohenfellner R. The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J Urol 1986;136:17±26. [2] Narayan P, Broderick GA, Tanagho EA. Bladder substitution with ileocecal (Mainz pouch). Br J Urol 1991;68:588±95. [3] Leissner J, Stein R, Hohenfellner R, KoÈhl U, Riedmiller H, SchroÈder A, et al. Radical cystoprostatectomy combined with Mainz pouch bladder substitution to the urethra: long-term results. Br J Urol 1999; 83:964±70. [4] Abol-Enein H, Ghoneim MA. A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. A preliminary report. J Urol 1994;151:1193±7. [5] Abol-Enein H, Ghoneim MA. Further clinical experience with the ileal W-neobladder and a serous-lined extramural tunnel for orthotopic substitution. Br J Urol 1995;76:558±64. [6] Abol-Enein H, Ghoneim MA. A technique for the creation of a continent cutaneous urinary outlet: the serous-lined extramural ileal valve. Br J Urol 1996;78:791±2. [7] Abol-Enein H, Ghoneim MA. Serous-lined extramural ileal valve: a new continent urinary outlet. J Urol 1999;161:786±91. [8] 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. [9] Kato H, Lizuka K, Igawa Y, Nõshõzawa O. Serous-lined extramural tunnel technique for uretero-ileal implantation in urinary diversion. Int J Urol 1999;6:145±8. [10] Kato H, Kõyokawa H, Igawa Y, Nõshõzawa O. The serous-lined tunnel principle for urinary reconstruction: a more rational method. Br J Urol 2001;87:783±8. [11] Papadopoulos I, Weichert-Jacobsen K. Experiences with the enteroureteral anastomosis võa the extramural serous-lined tunnel: Procedure of Abol-Enein. Urology 2001;57(2):234±8. [12] Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. Complications and functional results in 363 patients after 11 years of follow-up. J Urol 1999;161:422±8. [13] Elmajõan DA, Stein JP, Esrig D, Freeman JA, Skinner AC, Boyd SD, et al. The Kock ileal neobladder: updated experience in 295 male patients. J Urol 1996;156:920±5. [14] Studer UE, Zingg EJ. Ileal orthotopic bladder substitutes. What we have learned from 12 years experience with 200 patients. Urol Clin N Am 1997;24:781±93. [15] Jakobsen H, Steven K. Lack of effect of cholinergic blocking and alpha-adrenergic stimulation on nocturnal incontinence after ileocaecal bladder replacement. A controlled randomised study. Br J Urol 1989;63:379±83. [16] Berglund B, Kock NG, Norlen L, Philipson BM. Volume capacity and pressure characteristics of the continent ileal reservoir used for urinary diversion. J Urol 1987;137:29±34. [17] Iwakiri J, Gill H, Anderson R, Freiha F. Functional and urodynamic characteristics of an ileal neobladder. J Urol 1993;149:1072±6. [18] Kock NG, Ghoneim MA, Lycke KG, Mahran MR. Replacement of the bladder by the urethral Kock pouch: functional results. J Urol 1989;141:1111±6. [19] Miller K, Wenderoth UK, de Petriconi R, Kleinschmidt K, Hautmann R. The ileal neobladder: operative technique and results. Urol Clin N Am 1991;18:623±30. [20] El Bahnasawy MS, Osman Y, Gomha MA, Shaaban AA, Ashamallah A, Ghoneim MA. Nocturnal enuresis in men with an orthotopic ileal reservoir: urodynamic evaluation. J Urol 2000;164:10±3. [21] Lobel B, Guille F, Olivo JF, Gosselin A, Goldwasse B. Intestinal motility and its variations in replacement bladder and intestine. Acta Urol Belg 1991;59:35±47. [22] Stein R, Lotz J, Fõsch M, Beetz R, Prellwitz W, Hohenfellner R. Vitamin metabolism in patients with a Mainz pouch I: long-term followup. J Urol 1997;157:44±7.